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HEALTH    EDUCATION 
and  the  NUTRITION  CLASS 


HEALTH    EDUCATION 
and  the  NUTRITION  CLASS 

A  Report  of 
The  Bureau  of  Educational  Experiments 

Descriptive  and  Educational  Sections 
By  JEAN  LEE  HUNT 

Studies  of  Height  and  Weight  and  Mental  Measurements 
By  BUFORD  J.  JOHNSON,  Ph.D.  ; 

Report  on  Physical  Examinations  1919-20 
By  EDITH  M.  LINCOLN,  M.D. 


New  York 

E.  P.  BUTTON  &  COMPANY 

681  Fifth  Avenue 


d  6  S  S  S 


Copyright,  1921 
By  E.  P.  BUTTON  &  COMPANY 

All  Rights  Reserved 


Printed  in  the  "United  States  of  America 


e 


TO 

^lizabctli  #pra0ue  Caalibje 

WHOSE    GENEROSITY   HAS   MADE   POSSIBLE 

WHATEVER   CONTRIBUTION   THIS   STUDY   MAY   OFFER 

TOWARD  THE  BETTER  KNOWLEDGE  OF  CHILDHOOD, 

AND  THE  INCORPORATION  OF  SUCH  KNOWLEDGE 

IN  THE   school's   PRACTICE  AND  THINKING 


ACKNOWLEDGMENTS 

To  recall  the  history  of  the  Nutrition  Classes  at 
P.  S.  64  is  to  recall  devoted  service  and  generous 
contributions  of  many  kinds  and  from  many  sources. 
The  text  of  our  report  in  itself  reflects  the  coopera- 
tive nature  of  the  undertaking,  compiled  as  it  is  from 
a  diversity  of  special  and  partial  reports  made  by 
different  workers  at  various  stages  of  the  experi- 
ment. We  desire  to  make  special  acknowledgment 
to  the  following: 

To  Haeriet  M.  Johnson  who  as  our  General  Sec- 
retary organized  the  experiment,  secured  the  neces- 
sary facilities  for  it  and  the  requisite  permissions 
for  its  conduct  from  the  school  and  city  authorities, 
and  who  enlisted  the  cooperation  of  the  chief  workers 
and  agencies  identified  with  the  undertaking. 

To  Hareiet  Forbes,  at  whose  suggestion  the  ex- 
periment was  first  initiated  and  whose  untiring 
efforts  have  been  directed  to  the  improvement  of 
technique  for  the  enlistment  of  cooperation  from  the 
children  and  from  their  parents.  Miss  Forbes  has 
been  responsible  for  the  programs  of  class  instruc- 
tion and  home  contacts  in  the  second  and  third  years 
of  the  work,  and  has  contributed  the  social  study 
used  as  the  basis  of  Chapter  11. 

To  Frederick  W.  Ellis  whose  reinterpretation  of 
early  results  in  the  light  of  later  findings  has  con- 


viii  ACKNOWLEDGMENTS 

tributed  greatly  to  the  value  of  our  report  and  whose 
advice  and  criticism  have  been  invaluable  throughout 
the  experiment. 

To  Dr.  William  R.  P.  Emerson  who  assisted  in  the 
organization  of  the  work  and  directed  it  in  its  earlier 
stages  and  to  his  co-worker,  Miss  Mabel  Skilton. 

To  Dr.  David  Mitchell  who  made  the  computa- 
tions of  statistical  material  gathered  in  the  first  and 
second  years  of  the  experiment,  compiled  the  tables 
and  devised  the  charts  used  in  Chapters  III  and  IV. 

To  Miss  Bessie  Edwina  Beckwith^  and  Mis^ 
Louise  Schriefer  who  as  members  of  our  staff  have 
made  individual  contributions  to  methods  employed 
and  data  submitted,  and  to  Miss  Mary  Marot,  our 
Educational  Recorder,  for  the  reports  of  class  pro- 
cedure incorporated  in  Chapters  III  and  IV.  To 
Miss  Margaret  Vanderbilt  and  Miss  Margaret  Cobb 
who  have  given  volunteer  assistance  of  the  greatest 
value. 

To  Superintendent  "William  L.  Ettinger  of  the 
New  York  City  Schools  and  to  Dr.  Gustave  Straub- 
enmuller,  Acting  Superintendent  of  Schools  at  the 
time  our  experiment  was  initiated,  for  the  permis- 
sion by  which  we  were  enabled  to  conduct  our  classes 
in  a  public  school. 

To  Dr.  Louis  N.  Marks,  Principal,  and  those 
teachers  of  P.  S.  64  who  by  their  interest,  sympathy 
and  daily  cooperation  have  made  the  experiment 
possible. 


ACKNOWLEDGMENTS  ix 

To  Dk.  Josephine  D.  Baker  and  Dr.  Leopold 
Marcus,  of  the  New  York  City  Bureau  of  Child 
Hygiene,  through  whose  kind  cooperation  we  ob- 
tained the  special  facilities  of  open-air  class-rooms 
for  many  of  the  children  under  our  care. 

To  Dr.  Howard  Foster,  and  to  Bellevue  Hospital, 
the  Metropolitan  Hospital  and  the  Post  Graduate 
Hospital,  for  generous  assistance  in  cases  requiring 
special  examinations  or  operation  for  tonsil  and 
adenoid  defects. 

To  Dr.  Harold  A.  Koonz  and  Dr.  Louis  A. 
Leichter  for  generous  contributions  of  professional 
services  in  the  correction  of  dental  defects,  and  to 
the  workers  of  the  Stuyvesant  Clinic  and  the  Twenty- 
third  Street  Clinic  for  the  assistance  rendered  by 
them. 

To  the  workers  of  Christodora  House  and  to  the 
New  York  School  Lunch  Committee  of  the  Associa- 
tion for  Improving  the  Condition  of  the  Poor  for 
their  cooperation  in  the  program  of  school  feeding 
during  the  first  term  of  the  experiment. 

To  Dr.  Robert  Kahn  and  his  assistant,  Mrs.  B. 
G.  Eeid  of  the  New  York  City  Department  of  Health 
Eye  Clinic  for  their  unfailing  interest  and  coopera- 
tion during  the  entire  period  of  our  work,  and  to 
Dr.  I.  H.  GoLDBERGER  of  the  New  York  City  Depart- 
ment of  Health  for  the  special  physical  examinations 
made  by  him  of  children  under  our  care. 


FOREWOED 

By  publishing  this  detailed  study  of  our  experi- 
ment with  nutrition  classes  in  a  city  school,  it  is  our 
hope  to  place  at  the  disposal  of  other  workers  such 
an  account  of  the  experience,  of  the  questions  raised 
by  it,  and  of  the  varying  degrees  of  success  and  fail- 
ure attending  it,  as  may  serve  materially  to  further 
the  success  of  other  enterprises  in  the  same  'field 
of  service.  The  experiment  has  brought  to  us 
clearer  understanding  of  the  essential  problems  of 
health  education,  and  better  appreciation  of  its  true 
scope  and  possible  place  in  general  educational  pro- 
cedure. If  our  readers  will  consider  with  us  the 
successive  problems  incident  to  our  work  at  the  dif- 
ferent stages  of  its  development,  we  believe  they 
will  arrive  with  us  at  that  inevitable  conclusion  of 
educational  experiment,  the  beginning  of  further 
experiment,  with  enlarged  knowledge  and  improved 
technique  in  prospect.  Only  thus  may  we  account 
our  undertaking  successful  and  our  record  to  have 
served  its  purpose. 

The  Bueeau  of  Educational  Experiments. 

New  York  Crry, 
June,  1921. 


CONTENTS 

PAGES 

CHAPTER  I 
Place  of  the  Experiment 

Premises — The  General  Health  Problem — The  Problem 
OF  Malnutrition — Some  Misconceptions — Inadequacy 
OF  Attack — The  Experiment  Outlined 1-13 

CHAPTER  II 
The  Social  Backgroimd 

The  School   Population — Home   Environment — School   En- 
vironment         14-26 

CHAPTER  III 
The  Initial  Program 

Descriptive  Report — Statistical  Data  and  Interpretations 

— SlJMMARY 27-61 

CHAPTER  IV 
Development  of  Procedure — Grammar  Grades 

Descriptive  Report — Statistical  Data  and  Interpretations 

— Summary 62-97 

CHAPTER  V 
Development  of  Procedure — Primary  Grades 

Descriptive  Report — Report  on  Physical  Examinations.  . . .     98-117 

CHAPTER  VI 
Growth  in  Height  and  Weight 

Distribution  of  Percentages  Under  and  Overweight — 
Comparison  of  Underweight  and  Control  Groups — 
Seasonal  Variation — Comparison  of  Varying  Degrees  of 
Percentage  Underweight — Variations  in  Type — Inter- 
pretations— Summary  of  Procedure   1919-20 118-158 

xlii 


xiv  CONTENTS 

PAGES 

CHAPTER  VII 
Mental  Measurements  of  First  Grade  Children 

Group  Selection — Apparatus  and  Procedure — Tabulation 
OF  Results — Comparison  of  Nutrition  and  Control 
Groups — Motor  Coordination  of  Nutrition  Group — 
Summary 15&-198 

CHAPTER  VIII 

Interpretations  and  Recommendations  for  a 
Program  of  Research 

Standards    of    Growth — Causal    Factors    and    Response — 

Psychological  Implications 199-220 

CHAPTER  IX 

Interpretations  and  Recommendations  for  an 
Educational  Program 

Principles  Determining  Results — Criteria  for  Educa- 
tional Experiences  in  the  Health  Program — Impli- 
cations FOR  School  Procedure — Summary 221-257 

Appendices 258 


ILLUSTRATIONS 

Mid-  morning  Lunch  at  Christodoba  House 28 

Rest  and  Restlessness  in  the  Gymnasium  at  Christodoba 
House 44 

Comparing  Progbess — Open-aib  Boys  of  1918-19 62 


acv 


HEALTH    EDUCATION 
and  the  NUTRITION  CLASS 


HEALTH  EDUCATION 
AND  THE  NUTRITION  CLASS 


CHAPTER  I 
PLACE  OF  THE  EXPERIMENT 


PEEMISES 


The  experiment  here  recorded  was  undertaken  to 
explore  the  possibilities  of  the  nutrition  class  in  a 
public  school,  to  determine  how  far  a  school  can 
successfully  employ  the  nutrition  class  procedure, 
and  in  particular  how  far  the  procedure  itself  can 
be  expected  to  reinforce  the  school's  general  pro- 
gram of  health  education.  Our  classes  at  Public 
School  64,  Manhattan,  have  constituted,  we  believe, 
the  pioneer  attempt  to  remedy  malnutrition  in  a 
school  population  by  employing  the  methods  of  the 
hospital  nutrition  clinic  or  class  within  the  school. 
In  conducting  them,  however,  we  have  had  broader 
educational  interests  very  definitely  in  view,  and  our 
aim  has  been  primarily  the  enrichment  of  general 
educational  procedure  rather  than  the  development 
of  special  provisions  for  children  needing  particular 
care. 

The  health  program  of  the  school,  if  it  is  to  be 
developed  in  accordance  with  educational  conceptions 

1 


2  HEALTH  EDUCATION 

of  the  present  day,  must  conform  to  the  general 
thesis  that  the  child's  environment  shall  afford  the 
conditions  for  certain  necessary  experiences,  and 
that  his  intelligent  cooperation  with  regard  to  these 
experiences  must  be  secured;  it  must  give  to  the 
school  and  to  the  individual  child  within  the  school 
a  creative  attitude  toward  the  problem  of  health; 
it  must  function  appreciably  in  better  habits  of 
health  and  in  better  individual  well-being. 

Moreover,  if  such  a  school  program  is  to  be  ade- 
quate as  a  health  program,  its  development  requires 
the  services  of  the  physician  and  of  other  specialists 
in  several  fields  of  science,  for  the  school  cannot  be 
expected  to  take  over  and  handle  through  its  regular 
professional  staff  a  serious  attack  on  the  technical 
problems  involved.  Thus  the  situation  of  the  school 
in  regard  to  health  education  is  characteristic  of  its 
situation  with  regard  to  any  supplementary  activity 
involving  a  considerable  body  of  specific  knowledge 
or  particular  technique  for  its  conduct.  The  great 
majority  of  teachers  to-day  are  but  inadequately 
equipped,  so  far  as  understanding  of  the  science  and 
technique  of  their  own  profession  is  concerned.  To 
demand  that  the  class-room  teacher  shall  be  conver- 
sant with  any  considerable  outside  body  of  scientific 
facts  or  any  highly  developed  technique  belonging  to 
another  profession,  is  to  demand  the  impossible.  It 
is  only  as  specialists  from  other  fields  can  enter  the 
school,  introducing  their  own  techniques  and  adapt- 
ing them  to  the  school's  requirements,  that  their 
various  contributions  to  the  service  of  childhood  can 
be  successfully  incorporated  with  school  activities, 


PLACE  OF  THE  EXPERIMENT  3 

and  the  school's  thinking  and  service  correspond- 
ingly broadened. 

It  is  in  this  field  of  educational  experience  that  the 
Bureau  of  Educational  Experiments  has  been  par- 
ticularly interested  to  work.  The  position  of  the 
school  makes  it  the  logical  clearing-house  for  those 
members  of  the  community  who  hold  in  their  united 
thinking  the  community's  available  knowledge  in 
regard  to  children  and  their  needs,  and  the  attempt 
to  bring  together  cooperatively  the  school  and  the 
specialists  best  prepared  to  deal  with  children's 
problems,  presents  in  our  estimation  an  opportunity 
for  educational  experiment  offering  particular 
promise  for  the  future. 

Thus  a  number  of  considerations  led  us  to  experi- 
ment with  the  nutrition  class  as  a  tentative  proce- 
dure in  a  school  program.  It  was  in  essential  agree- 
ment with  our  educational  thesis.  It  necessitated 
introducing  within  the  school  the  services  of  the 
pediatrist  and  of  his  trained  social  service  assistants 
and  relating  their  special  knowledge  and  techniques 
as  closely  as  possible  to  the  school's  problems  and 
the  school's  thinking.  It  offered  an  attack  on  health 
from  the  positive  side.  If  by  its  adoption  the  school 
could  secure  a  satisfactory  procedure  and  appre- 
ciable gains  for  underweight  children,  we  believed 
it  would  at  the  same  time  serve  to  demonstrate  the 
essential  features  of  a  general  program  of  health 
education  much  needed  at  the  present  time. 

THE  GENERAL  HEALTH  PROBLEM 

We  have  had  abundant  illustration  during  the 
years  just  past  of  the  importance  of  physical  fitness 


4  HEALTH  EDUCATION 

to  the  national  life.  Attention  has  been  increasingly 
focussed  on  problems  of  public  health  and  it  has  been 
unnecessary  to  contemplate  disasters  in  foreign 
lands  for  our  own  experience  with  such  epidemics 
as  those  of  ''polio"  and  ''flu"  have  brought  into 
general  public  consciousness  the  importance  of  meas- 
ures for  health  conservation.  We  have  all  witnessed 
the  dramatic  sequence  of  events  attending  army  re- 
cruiting,— the  rejection  of  great  numbers  of  young 
men  because  of  physical  defects,  the  raising  to  maxi- 
mum physical  well-being  of  the  men  in  training 
through  the  carefully  regulated  regime  of  the  camp,* 
and  to-day  the  third  stage  of  the  object  lesson,  the 
waning  of  that  standard  of  well-being  among  the  men 
mustered  out  as  they  go  back  to  the  daily  occupations 
and  ill-regulated  regime  of  American  private  life. 

Possibly  no  circumstances  less  dramatic  would  have 
served  to  arouse  public  consciousness  to  the  needs 
of  the  situation.  Certainly  there  is  throughout  the 
country  to-day  a  very  general  interest  in  problems 
of  public  health  and  a  desire  for  betterment.  The 
outstanding  fact  that  must  be  evident  to  all  is  the 
need  of  a  nation-wide  program  of  prevention  rather 
tljan  correction,  and  the  inadequacy  of  such  limited 
lines  of  attack  as  military  training  and  athletic  pro- 
grams on  the  one  hand,  and  the  traditional  activities 
of  medical  and  welfare  agencies  on  the  other. 

THE  PROBLEM  OF  MALNUTRITION 

The  problem  of  malnutrition  among  school  chil- 
dren plays  an  important  part  in  this  general  health 

•  Chamberlain,  Col.  Wm.  P.,  Effects  of  Army  Life  on  the  Health 
of  Men,  Proc.  Int.  Conf.  Women  Physicians,  Vol.  I,  p.  244.  Womans 
Press,  1920. 


PLACE  OF  THE  EXPERIMENT  5 

problem.  It  is  claimed  to  be  largely  responsible  for 
after  ills  and  weaknesses  in  later  life.  Its  chief 
causes  are  main  factors  in  the  general  public  health 
problem,  and  a  successful  attack  upon  it  in  any  group 
or  community  may  be  assumed  to  typify  in  miniature 
the  kind  of  attack  required  in  any  comprehensive 
campaign  on  a  nation-wide  scale. 

Prevalent  as  the  condition  is  to-day  it  was  hardly 
recognized  as  a  school  problem  ten  years  ago.  We 
have  only  to  examine  the  past  reports  of  school 
medical  inspectors  to  realize  how  little  it  figured  in 
their  thinking.  Take  for  example  the  figures  given 
for  New  York  City  Schools  in  1911  *  where  malnu- 
trition is  reported  as  affecting  2.57o  of  the  total 
number  of  children  examined,  and  compare  them 
with  the  total  of  17.77o  similarly  reported  in  1920.t 
A  survey  of  43  schools  in  the  poorer  districts  of  the 
city  made  in  1918  revealed  a  percentage  in  one  school 
population  of  61%  affected  and  32%  as  the  average 
found  for  the  whole  number  surveyed.^  While  these 
last  figures  represent  extreme  conditions  and  at  once 
suggest  questions  as  to  the  standards  used  in  obtain- 
ing them,  the  testimony  of  school  and  health  author- 
ities the  country  over,  in  rural  as  well  as  in  urban 
communities,  is  unanimous  in  its  emphasis  on  the 
prevalence  of  the  condition. 

We  may  account  for  this  astonishing  increase  only 
by  taking  into  consideration  two  types  of  factors 
that    have    been   working    consistently    toward    it 

*  Gulick  and  Ayres,  Medical  Inspection  of  Schools,  Eussell  Sage 
Foundation  Monograph,  1913,  Table  p.  40. 

t  Monthly  Bulletin,  Dept.  of  Health,  City  of  New  York,  May,  1921. 

t  Baker,  Josephine  D.,  Annual  Report,  Bureau  of  Child  Hygiene, 
Dept.  of  Health,  City  of  New  York,  1918. 


6  HEALTH  EDUCATION 

in  recent  years.  First  among  these  is  the  grow- 
ing recognition  of  the  condition  as  one  of  ill-health, 
or  at  least  of  ill-being.  A  few  years  ago  only  ex- 
treme cases  were  recognized.  With  greater  knowl- 
edge, however,  has  come  the  emergence  of  standards 
for  diagnosing  malnutrition,  among  them  the  now 
generally  accepted  height-weight-age  index.  Such 
standards  as  we  have  are  still  most  imperfect,  yet, 
such  as  they  are,  they  are  widely  accepted  and  play 
an  important  part  in  the  rise  of  the  percentage 
reported  to-day  as  against  that  reported  ten  years 
ago. 

Developing  standards  of  nutrition  do  not,  how- 
ever, sufficiently  account  for  everything.  The 
lowered  standard  of  living  during  the  war  period, 
when  certain  necessary  commodities,  as  butter-fats, 
meats  and  sugar,  became  scarce  and  unduly  expen- 
sive, and  the  increased  cost  of  living  exceeded  in  the 
majority  of  homes  whatever  increase  to  the  family 
income  was  contributed  by  the  rising  wage-scale, 
has  undoubtedly  been  an  important  factor.  Yet,  in 
this  country  where  little  actual  want  existed,  where 
even  in  the  greatest  crises  of  the  war  food  has  been 
sufficient  and  employment  general,  the  resulting 
drop  in  the  standard  of  well-being  among  our  children 
seems  to  demand  further  explanation.  The  theory 
that  the  average  standard  of  living  in  American 
homes  does  not  provide  for  the  maximum  well-being 
of  the  individual,  and  is  indeed  so  near  the  margin 
of  ill-being  that  it  permits  of  no  reduction  without 
an  immediate  resulting  drop  below  the  safety  line, 
probably  offers  the  most  satisfactory  hypothesis  and 


PLACE  OF  THE  EXPERIMENT  7 

one  that  the  workers  concerned  in  our  experiment 
are  ready  to  support. 

SOME    MISCONCEPTIONS 

When  during  the  winters  of  1917  and  1918  the 
rapidly  increasing  percentage  of  malnutrition  among 
children  began  to  occupy  the  attention  of  the  public, 
popular  misconceptions  in  regard  to  its  causes, 
remedies,  and  results  to  the  individual,  became  evi- 
dent. First  among  these  was  the  relation  between 
malnutrition  and  hunger.  It  was  claimed  that  our 
schools  were  full  of  hungry  children  whose  parents 
were  unable  to  supply  them  with  necessary  food. 
Popular  discontent  and  alarm  at  rising  prices  added 
to  this  belief,  and  the  obvious  remedy  seemed  to  lie 
in  the  general  provision  of  school  lunches  at  nominal 
prices,  and  at  public  expense  for  those  unable  to  pay. 

In  the  brief  time  that  has  elapsed,  there  has  been 
a  considerable  accession  of  popular  knowledge  on 
this  subject,  and  it  is  almost  difficult  to  look  back 
to-day  and  understand  the  uncertainty  with  which 
such  statements  were  met  three  years  ago.  As  long 
as  our  chief  sources  of  information  in  regard  to  the 
existing  malnutrition  in  any  community  were  the 
welfare  and  hospital  agencies,  no  comprehensive 
view  of  the  situation  was  possible,  for  their  inquiry 
was,  perforce,  limited  to  those  candidates  for  relief 
applying  at  their  doors.  The  experience  of  the  pri- 
vate practitioner  with  individual  cases  hardly  car- 
ried over  into  the  general  picture  of  the  community 
and  its  needs,  and  the  conditions  in  middle  class  and 


8  HEALTH  EDUCATION 

wealthy  homes  were  thus  entirely  excluded  from  the 
picture. 

Comparatively  few  as  the  community  surveys  of 
malnutrition  through  the  agency  of  the  schools  have 
been,  the  light  they  have  thrown  on  the  relation  of 
malnutrition  to  economic  conditions  has  been  clari- 
fying. Foremost  among  such  attempts  must  be 
noted  the  survey  of  1920  by  the  Elizabeth  McCor- 
mick  Memorial  Fund  in  Chicago,  where  the  height- 
weight-age  index  was  applied  to  10,000  children,  rep- 
resenting several  school  populations  from  different 
sections  of  the  city  that  presented  wide  contrasts  in 
economic  conditions.  Among  the  statistics  gathered, 
one  school  with  a  percentage  of  57.7  of  its  enroll- 
ment underweight  was  reported  from  "a  comfort- 
able semi-suburban  neighborhood,"  as  contrasted 
with  16.2%  for  one  school  of  ''the  stockyards  dis- 
trict." This  is  undoubtedly  the  clearest  answer  yet 
returned  to  the  misconception  that  confuses  hunger 
with  malnutrition.*  Hungry  children  may  be  pres- 
ent in  our  public  schools,  but  their  problem  does  not 
explain  the  more  general  one  of  malnutrition. 

Another  popular  conception  frequently  voiced  and 
less  easily  answered  is  that  malnutrition  results  in 
dulling  the  mental  faculties,  and  that  such  children 
are  mentally  handicapped.  That  hungry  children 
are  incapable  of  using  their  school  opportunities 
with  the  same  degree  of  profit  as  well-fed  children, 
hardly  needs  demonstration.    With  a  clear  picture 

*  Wood,  Mrs.  Ira  Couch,  Nutrition  Classes  in  the  Chicago  Schools, 
Modern  Medicine,  May,  1920. 

See  too,  Bliss,  D.  C,  Malnutrition  a  School  Problem,  El.  Seh. 
Journal,  March,  1921 — where  a  similar  survey  in  the  schools  of  Mont- 
clair,  N.  J.,  is  described.  The  poorest  section  of  this  city  made  the 
best  record. 


PLACE  OF  THE  EXPERIMENT  9 

of  the  facts  before  us,  however, — that  relatively  few 
of  the  malnourished  children  in  our  schools  are 
hungry  cases,  other  questions  arise,  for  another 
popular  conception,  still  current  in  many  sections, 
though  not  as  general  to-day  as  it  was  fifty  years 
ago,  is  the  idea  that  the  child  of  full  physical  vigor 
is  less  likely  to  make  a  good  student  than  one  of 
lower  vitality  and  less  abounding  activity. 

Inasmuch  as  science  has  been  unable  to  return 
unmistakable  answers  to  these  and  other  theories, 
popularly  held  and  confusing  to  the  issue,  the  prog- 
ress of  the  nation  as  a  whole  toward  better  standards 
of  well-being  has  been  definitely  retarded,  and  there 
still  remains  a  considerable  field  of  scientific  en- 
deavor to  be  covered  before  replies  can  be  presented 
in  terms  sufficiently  popular  and  convincing. 

INADEQUACY  OF  ATTACK 

If  the  general  conception  of  the  problem  has  been 
obscured  in  the  past  because  of  the  character  of  our 
sources  of  information,  the  attack  on  malnutrition 
has  been  subject  to  equally  serious  limitations, 
although  the  medical  profession,  social  agencies,  the 
school,  have  all  contributed  to  the  attempt.  The 
medical  profession  and  the  social  welfare  agencies 
have  of  necessity  focussed  their  efforts  on  the  cor- 
rective side,  working  for  immediate  results  to  the 
individual.  In  recent  years  the  development  of  social 
service  departments  in  connection  with  our  hospitals, 
and  the  emergence  of  the  visiting  nurse,  the  public 
health  nurse,  the  hospital  social  service  worker,  have 
resulted  in  a  closer  relationship  between  the  tech- 
niques of  the  social  agency  and  of  the  medical  pro- 


10  HEALTH  EDUCATION 

fession,  and  the  development  of  the  nutrition  clinic 
is  a  pooling  of  their  techniques  and  common  experi- 
ence. The  attack  of  the  school,  however,  until  a  very- 
recent  period,  was  a  fairly  isolated  one.  Recogniz- 
ing its  essential  function  to  be  educational  and  pre- 
ventive it  has  been  content  for  the  most  part  to  await 
long  term  results,  and  to  make  no  attempt  to  evalu- 
ate its  health  procedure  currently  in  terms  of  appre- 
ciable increase  to  individual  well-being.  The  hygiene 
lesson  of  the  physiology  class,  the  work  of  the  do- 
mestic science  and  home  economics  classes,  with  their 
instruction  limited  to  girls,  the  school  lunch  service, 
too  often  existing  where  it  existed  at  all,  on  a  purely 
commercial  basis, — none  of  these  possible  vehicles 
for  health  education  can  be  proven  (unless  in  some 
exceptional  cases)  to  have  functioned  definitely  in 
the  community  by  the  establishment  of  health  habits 
and  a  better  standard  of  physical  fitness.  Our  de- 
partments of  physical  education  at  their  best  are 
concerned  only  with  a  limited  portion  of  the  whole 
field  of  physical  education  and,  in  our  public  schools 
at  least,  are  for  the  most  part  entirely  inadequate 
in  their  provisions  for  that  portion  of  it  that  they 
do  attempt  to  cover.  The  medical  examiner  and  the 
school  nurse,  working  it  is  true  within  the  school 
building,  can  hardly  be  said  to  have  affected  educa- 
tional procedure.  Their  function  has  been  rather 
to  prevent  the  spread  of  infectious  diseases,  and,  so 
far  as  malnutrition  is  concerned,  to  diagnose  extreme 
individual  cases  and  refer  them  to  the  private  prac- 
titioner or  the  hospital  clinic.  Their  work  has  con- 
stituted the  school's  attack  on  the  corrective  side 
and  has  been  at  best  a  negative  one.     Thus  our 


PLACE  OF  THE  EXPERIMENT  11 

schools  cannot  be  said  to  have  developed  an>^vhere 
a  comprehensive  educational  procedure  calculated  to 
function  appreciably  in  better  habits  of  health,  to 
develop  a  creative  attitude  on  the  part  of  the  child 
towards  his  own  health,  or  to  lend  itself  to  current 
evaluation  in  terms  of  individual  well-being. 

THE   EXPERIMENT   OUTLINED 

It  will  be  evident  that  a  first  requisite  for  success- 
ful experiment  with  nutrition  classes  as  a  school 
procedure  is  the  cooperation  of  a  pediatrist  of  stand- 
ing in  his  profession  who  can  visualize  the  pos- 
sibilities of  such  an  experiment  and  who  in  his  own 
thinking  emphasizes  the  educational  attack.  Dr. 
Wm.  R.  P.  Emerson  of  Boston  has  been  the  pioneer 
among  pediatrists  in  calling  attention  to  the  serious 
consequences  of  malnutrition  among  school  children, 
and  in  recognizing  its  milder  stages  as  a  condition 
of  ill-being  if  not  of  actual  ill-health.  He  has  long 
recognized  the  important  part  played  by  education 
in  the  successful  treatment  of  such  cases,  and  since 
1908  has  used  a  technique  in  the  nutrition  clinic  of 
the  Massachusetts  General  Hospital,  now  widely 
known  as  the  ''Class  Method,"  by  which  the  work 
of  the  clinic  is  conducted  along  the  lines  of  a  class 
in  school.  A  visit  to  one  of  these  "nutrition  classes" 
in  the  Spring  of  1917  first  suggested  to  a  member  of 
our  organization  the  experiment  subsequently  tried 
by  us,  that  of  transferring  the  nutrition  clinic  or 
** class"  as  developed  by  Dr.  Emerson  in  the  out- 
patient department  of  the  hospital  to  a  public  school. 

In  the  fall  of  1917  we  enlisted  Dr.  Emerson's  in- 
terest in  our  plan,  and  later  when  we  accepted  the 


12  HEALTH  EDUCATION 

offer  of  P.  S.  64  as  a  school  laboratory,  we  secured 
his  services  for  organizing  the  work  and  training 
the  necessary  workers.  From  February,  1918,  when 
the  classes  began,  until  June,  1919,  Dr.  Emerson  was 
associated  with  us,  at  first  in  a  supervisory,  later 
in  an  advisory  capacity.  During  the  last  year,  1919- 
3920,  the  experiment  was  continued  with  our  own 
staff. 

The  original  program  as  agreed  on  with  Dr.  Emer- 
son was  an  adaptation  of  the  procedure  used  by  him 
in  the  clinic  of  the  Massachusetts  General  Hospital.* 
Our  special  interests  in  the  educational  and  research 
aspects  of  the  experiment  led  first  to  certain  changes 
of  detail,  and  later  to  substantial  divergence  as  to 
the  methods  employed.  In  addition,  certain  modifi- 
cations and  developments  were  made  to  meet  condi- 
tions imposed  by  the  school  and  community  environ- 
ment, and  by  unexpected  situations  that  developed 
in  the  course  of  the  work. 

In  June,  1921,  when  the  classes  were  discontinued, 
we  were  using  a  procedure  differing  in  many  re- 
spects from  the  initial  plan,  though  never  approxi- 
mating a  general  health  program.  Indeed  it  may  be 
well  to  realize  at  this  point  that  the  adoption  of  the 
nutrition  class  procedure,  by  confining  our  work  to 
underweight  children,  proved  confusing  to  our  ulti- 
mate purpose  for  the  entire  period.  To  the  workers 
actually  engaged  the  tendency  was  always  for  the 
corrective  procedure  to  become  the  all-important 
consideration,  and  as  increasing  public  recognition 
of  the  problem  of  malnutrition  further  emphasized 

*  For  a  description  of  this  procedure  see  Standards  of  Child  Wel- 
fare, Publication  No.  60,  Conference  Series  No.  1.  Children's  Bureau, 
U.  8.  Dept.  of  Labor,  1919,  pp.  238-241. 


PLACE  OF  THE  EXPERIMENT  13 

the  existing  need  of  corrective  work,  our  experiment 
was  naturally  looked  to  for  practical  suggestions  as 
to  the  conduct  of  a  corrective  program  in  the  school. 
Thus  the  corrective  aspect  has  always  played  a 
larger  part  in  the  experiment  than  was  anticipated 
by  us  and  has  largely  dictated  the  lines  of  develop- 
ment followed.  It  is  probable,  however,  that  the 
experience  has  gained  in  some  respects  by  this  fact, 
for  the  increased  emphasis  placed  by  the  corrective 
procedure  on  the  securing  of  results  to  the  individ- 
ual, reinforces  an  educational  program  at  its  weak- 
est point. 

In  addition  to  special  provisions  for  physical 
diagnosis  and  care  of  individuals  showing  defects 
or  morbid  conditions,  the  nutrition  class  calls  for  a 
daily  regime  of  good  eating  habits,  abundant  food, 
frequent  rest,  constant  fresh  air.  To  provide 
adequate  conditions  in  respect  to  these  essentials 
the  cooperation  of  the  adults  responsible  for  the 
twenty-four  hour  environment  of  the  child  is  de- 
manded. It  seems  desirable,  therefore,  before  dis- 
cussing the  procedure  used  in  detail,  to  describe  the 
environmental  conditions  of  the  community  in  which 
we  worked,  both  in  the  homes  and  at  the  school. 


CHAPTER  II 
THE  SOCIAL  BACKGROUND 

THE  SCHOOL  POPULATION 

The  necessary  arrangements  preliminary  to  the 
experiment  were  not  completed  until  January,  1918, 
for  in  addition  to  enlisting  the  interest  and  securing 
the  necessary  permission  from  the  school  authorities, 
the  question  of  a  suitable  school  plant  was  one  for 
serious  consideration.  For  years  the  City  of  New 
York  has  been  behind  in  its  school-building  program, 
and  the  increasing  shortage  of  labor  and  material 
since  1914  has  greatly  increased  the  problem.  The 
consequent  overcrowding  of  the  school-buildings  has 
made  space  for  additional  activities  problematical 
in  the  majority  of  schools,  and  this  factor  in  itself 
rendered  opportunities  for  a  pioneer  undertaking 
very  limited.  Quite  as  important  was  the  problem 
of  school  population.  As  our  undertaking  involved 
intimate  questions  of  home  surroundings  and  habits 
of  personal  hygiene,  considerations  of  economic 
status,  racial  stocks  and  foreign  customs  assumed 
particular  importance  for  it.  The  desideratum 
would  have  been  a  school  population  representative 
of  the  typical  American  home,  but  the  New  York 
schools  can  offer  few  such  opportunities.  Instead, 
there  is  a  choice  of  districts  predominately  Italian, 
Bohemian,  Irish,  Jewish,  as  against  more  hetero- 

14 


THE  SOCIAL  BACKGROUND  15 

geneous  units.  As  to  economic  conditions,  it  was  our 
purpose  from  the  first  to  avoid  the  poorest  districts. 
Obviously,  those  sections  which  furnish  annually  the 
greatest  number  of  candidates  for  relief  do  not  pre- 
sent an  adequate  opportunity  for  securing  or  evalu- 
ating results  from  an  educational  program.  Public 
School  64,  where  we  finally  accepted  the  opportunity 
to  conduct  our  classes,  offered  a  fairly  homogeneous 
Jewish  population,  in  a  section  somewhat  removed 
from  the  worst  slums,  though  the  neighborhood  is 
crowded  and  unsightly. 

HOME  ENVIRONMENT 

The  social  and  home  environment  of  the  East  side 
child  has  become  fairly  familiar  through  many  care- 
ful reports*  made  in  the  general  interest  of  child 
welfare,  and  for  the  purposes  of  this  study  it  is  prob- 
ably sufficient  to  discuss  only  those  aspects  which 
have  particular  bearing  on  the  problem  of  nutrition. 
No  thorough-going  analysis  of  the  economic  situation 
is  attempted,  therefore,  but  rather  a  record  of  cer- 
tain problems  reported  by  our  home  visitors,  expe- 
rienced social  workers  who  for  years  have  studied  life 
in  the  tenements  and  poverty  in  its  varying  degrees, 
and  who  in  many  cases  have  been  admitted  into  the 
guarded  confidence  of  the  heads  of  families.  That 
there  is  an  abiding  fear  of  want  brooding  over  many 
homes  where  there  is,  at  present,  no  acute  distress 
is  undoubtedly  true,  but  there  are  also  many  families 
who  regard  their  present  surroundings  merely  as  a 

*  In  particular  see  Dewey,  Child  and  Ruml,  Methods  and  Besults  of 
Testing  School  Children,  pp.  134  and  141-150,  E.  P.  Button  &  Co., 
1920 — where  the  results  of  an  intensive  social  study  in  an  adjoining 
district  presenting  similar  features  are  given. 


16  HEALTH  EDUCATION 

foothold  till  they  become  prosperous  enough  to  move 
where  air  and  sunshine  do  not  command  so  high  a 
price.  In  none  of  the  homes  has  there  been  evidence 
of  inflated  incomes  due  to  war  industry.  Eather  has 
it  been  true  that  with  the  majority  there  has  been 
added  hardship,  due  to  the  increased  cost  of  living 
and  to  loss  of  their  wage-earning  members.  Few  of 
the  mothers  work  outside  of  the  home  and  a  rela- 
tively small  percentage  take  in  work.  Many  parents 
have  their  o^^^l  small  business,  the  wife  being  occu- 
pied much  of  the  time  in  helping  her  husband.  In 
a  number  of  cases  rent  is  reduced  or  given  free  in 
exchange  for  janitor's  service,  largely  performed  by 
the  mother  in  addition  to  her  home  duties. 

Relief  was  received  by  only  a  few  of  the  families 
concerned  in  our  study,  though  many  more  had  at 
some  time  been  kno^\Ti  to  charitable  agencies.  Self- 
help  and  self-respect  are  highly  prized  and  jealously 
guarded.  In  those  cases  under  our  observation 
where  illness  or  misfortune  had  resulted  in  the  ac- 
ceptance of  temporary  relief,  speedy  return  to  a 
position  of  independence  was  usual.  These  sterling 
qualities  and  their  attendant  reserve  rendered  infi- 
nitely difficult  the  task  of  the  nutrition  worker  whose 
problem  is  to  secure  modification  of  many  of  the 
intimate  details  of  family  life. 

As  has  been  said,  the  population  of  this  quarter 
is  almost  entirely  Hebrew,  the  great  majority  being 
of  Russian  origin,  the  remainder  are  principally 
from  Austria,  with  a  scattering  of  Galicians,  Hun- 
garians and  Rumanians  and  a  few  Italians.  The 
older  generation  is  fairly  orthodox,  consequently 
there  is  present  the  serious  problem  of  family  dis- 


THE  SOCIAL  BACKGROUND  17 

integration  and  friction  between  older  and  younger 
members  that  obtains  wherever  such  conditions  are 
found.  The  public  school  is  an  important  factor  in 
this  family  problem  for  it  is  mainly  through  the 
school  that  the  younger  generation  is  Americanized. 
Our  schools  in  the  main  have  had  but  little  under- 
standing of  this  situation  in  the  foreign  family,  and 
few  have  developed  a  technique  whereby  the  neces- 
sary instructions  and  messages  to  the  home  shall 
appear  less  like  commands  to  the  older  from  the 
younger  generation,  who  are  entrusted  to  deliver 
them.  **You  tell  your  mother,"  the  usual  teacher's 
formula,  becomes  an  unthinkable  medium  for  trans- 
mitting directions  as  to  diet,  sleep  and  clothing.  The 
nutrition  worker  is  keenly  aware  too  of  the  impor- 
tance of  strife  and  emotional  disturbances  in  rela- 
tion to  her  problem.*  A  technique  which  will  avoid 
any  widening  of  this  breach  between  parents  and 
children  must  be  hers  if  she  would  succeed,  and  her 
problem  should  otfer  more  than  a  suggestion  for 
general  school  practice  when  the  foreign  home  is  to 
be  reached. 

Since  the  diet  is  in  the  hands  of  the  mother,  it 
remains  true  to  tradition  and  unaffected  by  the  fac- 
tors which  are  in  process  of  modifying  the  lives  of 
the  younger  generation.  The  standards  imposed  by 
the  Hebrew  ritual  are  strictly  adhered  to,  and  there 
is  little  realization  of  other  standards.  Ceremonial 
** cleanliness"  is  accepted  as  absolute  cleanliness, 
with  an  acquiescence  that  is  at  times  startling.  Our 
workers  found,  however,  no  lack  of  food  and  of  good 

*  Cannon,  Walter  B.,  Bodily  Changes  in  Fain,  Hunger,  Fear  and 
Bage,  D.  Appleton  &  Co.,  1915. 


18  HEALTH  EDUCATION 

food  in  the  majority  of  homes.  Insufficient  knowl- 
edge of  the  properties  of  foods  and  faulty  food 
habits  were  the  evident  factors  militating  against  the 
adequacy  of  the  home  dietary.  The  long  slow  cook- 
ing which  characterizes  most  of  their  dishes  has  its 
advantages  in  rendering  food  easily  assimilable,  but 
possibly  results,  too,  in  the  loss  of  some  of  the 
essential  vitamines  with  which  the  dietary  as  a  whole 
is  none  too  liberally  supplied.* 

For  years  the  public  has  been  more  or  less 
aware  that  many  children  come  to  school  mth- 
out  adequate  breakfast,  very  many  with  no  break- 
fast, and  much  restlessness  and  inattention,  with  con- 
sequent lowering  of  school  standing  is  attributed  to 
this  fact.  Social  workers  and  conservative  members 
of  our  school  boards  alike  seem  unaware  of  a  similar 
problem  existing  in  the  private  school  when  they 
argue  for,  and  against,  the  supplying  of  mid-morning 
lunches,  on  the  basis  of  economic  insufficiency  and 
the  pauperization  of  the  working  home.  Private 
schools  to-day  frequently  provide  a  light  lunch  of 
cocoa  or  milk,  and  crackers  or  bread  and  butter  for 
those  children  who  in  spite  of  long  hours  of  care- 
fully guarded  sleep  with  open  windows,  the  invigo- 
rating tonic  of  the  morning  bath,  and  the  well- 
appointed  breakfast  table,  are  wdthout  appetite  for 
food  in  the  early  morning.  On  inquiry  they  T\ill  be 
found  in  any  school. 

In  homes  like  those  of  the  children  of  P.  S.  64  we 
may  well  consider  whether  any  but  the  most  robust 
appetite   can    survive   the   conditions    surrounding 

•  Sohapiro,  Mary  L.,  Jewish  Dietary  Problems,  Journal  of  Home 
Eeonomics,  Feb.,  1919.  This  article  well  describes  the  characteristics 
of  the  Jewish  dietary  as  found  by  us  in  the  neighborhood. 


THE  SOCIAL  BACKGROUND  19 

breakfast  time.  In  most  instances  every  room  in  the 
flat  including  the  kitchen  is  used  for  sleeping,  and 
seldom  has  the  individual  child  the  common  right 
of  childhood  to  his  own  bed.  Bed  covering  seemed 
adequate  in  all  but  a  few  instances,  but  the  conti- 
nental fear  of  cold  night  air  obtains,  and  windows 
are  generally  kept  carefully  closed,  while  for  those 
able  to  afford  it,  the  indoor  air  is  further  vitiated 
in  winter  by  keeping  the  gas  range  burning  through 
the  night.  In  mild  weather  the  conditions  as  to  ven- 
tilation at  night  are  but  little  better,  as  the  rooms 
are  small,  and  at  least  two  out  of  the  four-room 
apartment  receive  their  air  only  from  a  narrow  inner 
court,  often  foul  with  odors  from  adjoining  apart- 
ments. 

The  congestion  within  the  flat  makes  breakfast  a 
disturbed  meal.  The  older  wage-earners  of  the  fam- 
ily who  must  needs  start  away  early,  are  given  pref- 
erence over  the  school  children,  who  have  been  late 
to  bed  and  for  whom  the  longer  rest  is  needed.  When 
finally  roused  the  little  people  are  torn  between  their 
desire  to  sleep  and  their  fear  of  being  late  at  school. 
With  barely  time  for  a  hasty  toilet  and  breakfast 
often  eaten  standing  or  walking  about,  the  result  is 
inevitable  haste  and  strife  on  the  part  of  the  child, 
or  an  apathy  which  a  nervous  and  irritable  mother 
attempts  to  overcome.  The  result  in  either  case  is 
a  disastrous  one.  The  habit  of  crowding  the  mouth 
and  washing  down  the  food  which  prevails  with 
large  numbers  of  school  children  is  often  begun  in 
this  way  and  is  most  difficult  to  break  down.  The 
unfinished  mastication  and  consequent  shortening  of 
the  process  of  mouth  digestion  is  no  doubt  frequently 


20  HEALTH  EDUCATION 

the  beginning  of  serious  interference  with  digestion, 
and  the  accompanying  hurry  and  irritation  renders 
a  thoroughly  unsatisfactory  meal  even  less  desirable. 
The  continental  custom  of  serving  only  rolls  and 
coffee  for  breakfast  is  the  rule,  and  only  occasion- 
ally does  one  find  eggs  or  cereal  added  as  a  result 
of  the  propaganda  for  better  feeding.  In  an  appre- 
ciable number  of  homes,  however,  cocoa  now  replaces 
coffee  for  the  children. 

The  noon  meal  is  usually  a  better  one,  though  delay 
in  its  preparation  or  too  great  haste  in  its  consump- 
tion because  of  the  child's  desire  to  have  time  for 
play  is  often  the  cause  of  friction  at  home.  It  is 
the  habit  in  some  cases  to  have  only  a  ''snack"  at 
this  time,  and  to  defer  till  school  is  over  any  attempt 
at  a  real  meal.  The  three  o  'clock  meal  of  some  sort 
is  usual,  and  may  or  may  not  be  a  hearty  one.  In 
the  main,  convenience  and  economy  urge  that  meals 
through  the  day  be  regarded  rather  as  "stayers" 
until  the  wage  earners  shall  return  home,  or  the  shop 
be  closed,  and  the  entire  family  can  assemble  for 
dinner,  which  is  accordingly  served  late,  often  at 
eight  or  even  nine  o'clock.  It  needs  little  imagina- 
tion to  realize  that  the  children,  after  a  long  school 
day  and  hours  of  strenuous  play  in  the  street,  are 
not  able  properly  to  digest  this  late  meal,  even  were 
the  menu  planned  with  better  regard  for  their  years. 

The  dinner  consists  usually  of  soup,  which  is  re- 
garded as  an  essential  dish,  meat,  frequently  chicken, 
and  such  vegetables  as  potatoes,  onions,  beets  and 
(cooked)  cabbages.  No  salads  or  greens  are  found 
in  the  Jewish  dietary  and  few  puddings,  though 
cakes  of  various  sorts  and  pastry  filled  with  fruit 


THE  SOCIAL  BACKGROUND  21 

or  cheese  are  used.  High  seasoning  and  condiments 
characterize  almost  all  the  dishes,  and  pickles  and 
mustard  in  quantity  are  rated  among  the  essentials 
of  a  satisfactory  menu  even  for  quite  little  children. 
Much  soda  water  is  consumed  between  meals  as  well 
as  cheap  candy.  The  homes  were  found  fairly  well 
supplied  with  the  more  usual  fruits,  apples,  oranges 
and  bananas. 

The  amount  of  milk  used  in  these  homes  is  for  the 
most  part  far  below  the  daily  pint  per  individual 
recommended  by  Dr.  Sherman  of  Columbia  and 
others,  and  cutting  down  of  the  customary  supply 
is  one  of  the  first  economies  to  which  the  family  in 
straitened  circumstances  has  recourse.  The  Jewish 
restriction  on  the  use  of  milk  and  milk  products  at 
any  meal  where  meat  forms  part  of  the  menu,  limits 
the  consumption  of  butter  as  well  as  of  milk,  and 
this  restricted  use  of  butter  plays  an  important  part 
in  making  vegetables  less  savory  and  therefore  less 
popular  than  they  should  be.  While  there  is  a  gen- 
eral understanding  that  "loose  milk"  should  not  be 
used  until  ''boiled,"  ideas  on  the  subject  are  far 
from  clear.  There  is  a  general  impression  that  all 
milk  is  unhealthf  ul  unless  taken  warm  or  hot,  and  that 
changes  in  its  properties  may  attend  heating  is  quite 
unknown.  Even  the  best  grade  of  bottled  milk  will 
often  be  placed  immediately  on  the  gas  stove  and 
allowed  to  heat  indefinitely.  It  will  be  obvious  that 
much  of  the  dislike  for  milk  found  among  the  chil- 
dren may  be  traced  to  this  method  of  treating  it. 

Cold  running  water  is  supplied  in  these  homes 
but  bathing  and  toilet  facilities  are  poor.  In  the 
majority  of  cases  the  occupants  of  the  four  or  more 


22  HEALTH  EDUCATION 

flats  on  a  floor  share  a  single  toilet,  ill-lighted  and 
poorly  ventilated.  Even  where  more  modern  ap- 
pointments exist  and  the  flat  contains  a  bathroom, 
family  habits  are  but  little  affected  by  the  added 
facility  and  the  school  weight-taking  discloses  only 
too  many  grimy  little  bodies,  whose  clogged  pores 
have  little  chance  to  play  their  part  in  the  man-build- 
ing process. 

At  the  age  of  six  the  sons  of  the  orthodox  must 
begin  attendance  at  the  rabbi 's  school  for  instruction 
in  the  faith  and  in  the  Hebrew  tongue.  The  sessions 
follow  directly  after  dismissal  from  the  public  school 
and  although  the  compulsory  time  is  brief  in  the 
early  years,  at  first  only  fifteen  minutes  a  day,  the 
little  children  are  encouraged  to  stay  after  the  ses- 
sions and,  indeed,  the  younger  ones  are  often  sent  by 
their  mothers  to  be  taken  care  of  in  the  afternoons  in 
the  belief  that  they  Avill  be  safer  there  than  in  the 
streets.  Thus  physical  restraint  in  ill-ventilated  sur- 
roundings is  substituted  for  valuable  hours  of  play 
in  the  open  air,  and  the  older  boys  who  are  prepar- 
ing for  confirmation  in  the  faith  are  often  severely 
taxed  by  the  requirements  made  of  them  in  addition 
to  the  work  and  hours  of  their  regular  school  day. 
It  would  seem  as  if,  between  the  crowded  home  flat, 
the  crowded  school,  and  the  after-school  care  of  the 
rabbis,  few  stones  were  left  unturned  in  the  adult 
plan  of  this  environment  to  cut  the  child  off  from 
activity  in  the  open  and  a  constant  supply  of  fresh 
air.  But  were  we  to  inquire  as  diligently  into  the 
environment  provided  by  many  ''typical  American" 
homes  far  removed  from  any  kind  of  slum  surround- 
ings, there  is  at  least  a  probability  of  their  affording 


THE  SOCIAL  BACKGROUND  23 

a  fair  parallel  to  the  main  features  in  this  picture, — 
abundant  food,  inadequate  dietary  knowledge,  poor 
eating  habits,  inadequate  sleep  and  inadequate  fresh 
air. 

SCHOOL  ENVIRONMENT 

Public  School  64  has  one  of  the  largest  and  best 
equipped  school  plants  in  the  city  and  offers  special 
facilities  in  its  manual-training  shops,  auditorium, 
yard  space,  open  air  and  ungraded  classes.  The 
principal,  Dr.  Louis  Marks,  is  keenly  interested  in 
educational  progress  and  has  frequently  cooperated 
with  outside  agencies  in  securing  special  activities 
and  facilities  for  the  school.  Thus,  the  attitude, 
not  only  of  the  principal  but  of  the  teaching  staff, 
is  one  of  far  greater  interest,  understanding  and  tol- 
erance for  supplementary  activities  than  is  usually 
the  case.  Unusual  opportunities  for  supplementing 
the  school  resources  are  to  be  found  in  the  near 
proximity  of  Tompkins  Square  with  its  big  play- 
ground and  of  such  community  agencies  as  the  Boys' 
Club  on  Avenue  A,  the  nearby  branch  of  the  city 
library,  and  Christodora  Settlement  House,  which 
stands  adjacent  to  the  school. 

Because  of  its  extensive  shop  equipment  the  school 
has  for  some  years  been  used  almost  entirely  for 
boys,  girls  being  admitted  only  in  the  Terman 
classes.  (See  p.  29.)  This  predominance  of  boys 
in  the  school  population  has  had  its  effect  on  the 
experiment  in  certain  particulars.  Much  of  our 
work  was  concerned  with  the  fifth  and  sixth  grade 
boys,  whom  we  must  assume  to  be  at  that  stage  of 
prepubertal  development  characterized  by  minimum 


24  HEALTH  EDUCATION 

growth  when  the  individual  is  probably  least  able  to 
respond  to  favorable  conditions,  and  appreciable 
results  from  treatment  are  likely  to  be  minimized. 

Food. — The  time  is  not  yet  when  the  public  school 
can  gratify  the  small  boy's  native  interest  in  food 
by  admitting  him  to  a  cooking  class,  and  domestic 
science  equipment  was,  of  course,  entirely  lacking 
as  were  lunch-room  facilities.  During  the  first  year, 
when  a  mid-day  meal  was  included  in  the  nutrition 
program,  it  was  supplied  by  the  New  York  School 
Lunch  Committee  and  served  in  Christodora  House 
where  special  opportunities  for  rest  periods  were 
also  provided. 

Fresh  Air, — The  importance  of  the  air  supply 
in  relation  to  the  processes  of  assimilation  is  too 
little  understood,  and  public  opinion  in  consequence 
too  little  informed,  for  school  conditions  generally  to 
reflect  the  influence  of  scientific  findings  in  regard 
to  temperature,  humidity  and  air  movement.  The 
equipment  for  heating  and  ventilation  at  P.  S.  64 
is  of  the  forced-air  type  generally  accepted  as  the 
best  in  modern  school  building  but  is  none  the  less 
open  to  some  serious  questions  on  the  score  of 
healthfulness.  The  atmosphere  of  the  class-rooms 
in  winter  is  undoubtedly  better  than  would  be  found 
in  the  majority  of  our  city  schools,  as  more  intelli- 
gent use  is  made  of  the  facilities  the  equipment 
affords  than  is  often  the  case,  but  it  is  probably  no 
exaggeration  to  say  that  the  air  is  at  all  times  too 
warm,  too  dry,  too  still  for  the  health  of  those  who 
must  spend  long  hours  there  five  days  a  week. 

If  by  fresh  air  we  mean  cool  air,  in  motion,  and 
of  optimum  humidity,  it  must  be  evident,  that  except 


THE  SOCIAL  BACKGROUND  25 

for  the  groups  in  open-air  rooms,  the  children  of 
our  nutrition  classes  did  not  receive  a  constant  sup- 
ply during  their  school  hours,  nor  probably  at  any 
other  hours  through  the  winter  weather,  save  in  their 
play  time  on  the  streets. 

Over-Fatigue  and  Bodily  Activity. — ^By  taking  the 
children  from  active  outdoor  play  for  a  considerable 
portion  of  the  day  and  imposing  the  seated  tasks  and 
quiet  of  the  class-room,  there  is  no  doubt  that  the 
school  prevents  much  over-exertion  on  the  part  of 
the  more  delicate  children.  However,  the  probable 
loss  to  the  average  child  resulting  from  the  school's 
restraint  of  bodily  activity  and  fixing  of  sedentary 
habits  is  of  far  greater  importance  for  the  general 
problem  of  health.  Until  the  significance  of  this  is 
more  generally  appreciated,  however,  school  tradi- 
tion and  equipment,  together  with  the  size  of  school 
classes,  will  continue  to  impose  conditions  where 
fatigue  results  from  lack  of  bodily  activity  rather 
than  because  of  it.  There  is,  moreover,  an  inevitable 
nervous  and  physical  stimulation  for  children  in  the 
mere  presence  of  other  children  in  numbers,  and  we 
may  w^ell  ask  ourselves  the  significance  in  terms  of 
nutrition  of  the  scrambling  crowds  gathered  about 
the  doors  of  P.  S.  64  before  each  session,  and  of  the 
general  tension  that  necessarily  attends  the  school 
day  where  3000  boys  are  housed  under  a  single  roof. 
It  seems  evident  that  such  conditions  demand  an 
increased  expenditure  of  energy  that  must  have  a 
direct  bearing  on  the  nutritional  processes  of  the 
individual. 

Additional  Facilities. — P.  S.  64  is  well  provided 
with  toilet  facilities  and  with  running  water  and 


26  HEALTH  EDUCATION 

drinking  fountains.  A  fine  gymnasium  equipped 
with  shower  baths  is  available  at  the  Boys'  Club 
nearby  and  another  is  provided  at  Christodora 
House.  These  are  used  by  many  of  the  older 
children. 


CHAPTER  III 

THE  INITIAL  PEOGRAM,  FEBRUARY-JUNE,  1918 

Basis  of  Selection- 

STANDARDS 

The  children  selected  for  our  nutrition  classes 
were  first  measured  for  height  and  weight,  the  Burk- 
Boas  Height- Weight-Age  Tables  being  used  as 
standards.*  Those  found  to  be  7%  or  more  under- 
weight became  candidates  for  enrollment,  although 
it  was  never  possible  to  enroll  them  all  because  of 
the  administrative  difficulties  involved.  The  use  of 
7%  as  a  standard  for  determining  malnutrition 
instead  of  the  more  usual  10%  standard,  was  in  ac- 
cordance with  Dr.  Emerson's  opinion  that  7% 
habitual  underweight  is  indicative  of  a  condition 
calling  for  attention.  In  our  practice,  however, 
because  of  the  necessity  the  school  was  under  of 
arranging  definitely  for  the  personnel  of  classes  at 
the  earliest  possible  date,  the  qualification  " habit- 
ual" had  to  be  disregarded  and  all  children  found 
7%  underweight  were  admitted  if  provision  could 
be  made  for  them.  While  we  realized  that  the  adop- 
tion of  so  high  a  standard,  especially  for  Jewish 
children  of  middle  European  antecedents,  was  open 
to  question,  we  employed  it  tentatively  throughout 

*  Burk,  Fredoric,  Growth  of  Children  in  Height  and  Weight, 
American  Journal  of  Psychology,  April,  1898. 

27 


28  HEALTH  EDUCATION 

the  experiment  with  a  view  to  making  an  assessment 
of  it,  and  of  any  special  possibilities  it  might  offer 
toward  a  program  of  preventive  work. 

GROUP  SELECTION 

Five  classes  were  organized  during  the  first  year. 
A  group  of  seventh  grade,  one  of  sixth  grade,  one 
of  first  grade  children,  a  group  of  children  from  one 
of  the  regular  open-air  classes,  and  a  group  from  the 
Terman  or  special  classes,  which  existed  as  an  experi- 
ment within  the  school,  were  included.  In  addition,  a 
group  of  20  fifth  grade  boys  were  selected  and 
given  a  program  of  school  feeding  for  purposes  of 
comparison.  The  children  from  the  upper  grades 
were  recruited  in  the  belief  that  they  were  sufficiently 
advanced  in  school  to  cooperate  intelligently  in  the 
experiment.  The  nutrition  class  procedure  had  been 
developed  by  Dr.  Emerson  with  special  reference  to 
these  older  children,  and  the  addition  of  the  first 
grade  group  introduced  problems  of  standards  and 
of  teaching  methods  not  anticipated  in  his  original 
plan.  They  were  included  because  of  an  attempt  on 
the  part  of  the  school  to  give  particular  care  to  mem- 
bers of  the  entering  class,  with  a  view  to  insuring 
individual  adjustment  to  school  life.  It  was  believed 
that  the  nutrition  class  would  supplement  the  school 
program  effectively  by  affording  special  treatment 
for  those  showing  need  of  physical  attention.  A 
program  of  health  education  carried  out  for  six- 
year-olds  seemed  to  offer,  too,  the  logical  beginning 
for  a  general  health  program  in  the  school.  The 
children  of  the  open-air  group  were  included  partly 
because  their  condition  as  anaemic  and  pre-tuber- 


THE  INITIAL  PROGRAM  29 

cular  cases  demanded  every  assistance  the  school 
was  able  to  afford,  partly  because  their  inclusion  was 
the  best  response  the  school  could  offer  to  Dr.  Emer- 
son's request  for  open-air  treatment  and  a  lighter 
program  of  school  work.  The  Terman  classes  were 
included  because  of  special  interest  of  the  school  in 
them,  and  the  fact  that  a  surprisingly  large  percent- 
age of  underweight  was  found  to  exist  among  them. 

THE  TEKMAN  CLASSES 

These  classes  consist  of  gifted  children  whose  devi- 
ation from  the  average  intelligence  quotient  repre- 
sents about  the  same  range  above  normal  as  that  of 
the  defective  in  the  ungraded  classes  does  below.  As 
children  showing  an  I.  Q.  of  75  or  less  are  placed 
by  the  school  in  special  classes  for  defectives,  so 
those  showing  an  I.  Q.  of  125  or  above  have  special 
provision  made  for  them  in  the  Terman  classes.  This 
experiment  was  in  its  initial  stages  at  the  time  the 
nutrition  classes  began  and  was  at  that  time  limited 
to  the  sixth,  seventh  and  eighth  grades.  In  all,  69 
children  had  been  withdrawn  from  these  grades  and 
placed  in  two  groups,  one  of  which  graduated  in  the' 
spring  of  1918,  the  other  the  following  year.  The 
average  I.  Q.  was  considerably  beyond  125  and  some 
individual  ratings  were  much  higher.  The  classes 
included  girls  as  well  as  boys,  and  the  age  range 
was  from  ten  to  twelve  years. 

The  children  in  the  more  advanced  group  very 
generally  exhibited  the  accelerated  height  increase, 
and  consequent  decrease  of  weight  for  height  due  to 
the  approach  of  puberty.  This  factor  undoubtedly 
contributed  somewhat  to  the  percentage  of  under* 


30  HEALTH  EDUCATION 

weight  recorded  among  them,  as  the  Burk-Boas 
Height- Weight- Age  Index  is  based  principally  on  the 
measurements  of  children  of  other  racial  anteced- 
ents, in  whom  pubertal  development  presumably 
takes  place  at  a  less  early  age.  They  were,  however, 
at  no  greater  disadvantage  in  respect  to  this  factor 
than  were  the  children  of  the  regular  sixth  and 
seventh  grades  who  showed  by  the  same  standard 
percentages  of  15.9  and  14.4  respectively  in  compari- 
son with  the  27.5  average  of  the  Terman  class.  A 
corresponding  contrast  is  presented  by  the  percent- 
age of  overweight  found  among  the  Terman  and 
regular  grade  children,  the  sixth  and  seventh  grades 
showing  a  percentage  of  18.7  overweight  and  the 
Terman  groups  a  percentage  of  only  8.6.* 

The  general  impression  created  by  these  gifted 
classes,  however,  was  one  of  physical  superiority 
rather  than  the  reverse.  Their  relatively  poor  show- 
ing in  the  initial  height  and  weight  taking  created 
considerable  surprise;  and  even  after  the  stripped 
examinations  had  revealed  the  usual  characteristics 
— winged  scapulae,  poor  muscle  tone,  prominent  rib 
bones,  etc. — their  faces,  alert  and  often  rosy,  seemed 
to  contradict  the  evidence. 

Possibly  three-fourths  of  them  came  from  homes 
distinctly  above  the  general  economic  level  of  the 
district.  This  was  primarily  due  to  the  higher  aver- 
age intelligence  of  their  parents,  for  whom  the  diffi- 
culties of  getting  a  foot-hold  in  America  had  been 
reduced  by  their  exceptional  ability.  A  number  were 
children    of   East    side   physicians   who   combined 

•  Seven  per  cent  or  above  in  excess  of  normal  is  the  basis  on  which 
this  overweight  is  computed.  See  Distribution  Table,  Appendix  A., 
also  Tables  I  and  II,  pp.  49-50. 


THE  INITIAL  PROGRAM  31 

the  advantages  of  education  with  those  of  superior 
intellect.  The  less  prosperous  represented  families 
where  some  special  factor,  like  relatively  recent  im- 
migration and  consequent  difficulty  with  a  foreign 
language,  kept  the  family  fortunes  at  a  lower  level 
in  spite  of  native  ability. 

The  members  of  the  older  class  were  looking  for- 
ward to  graduation  in  the  spring,  and  were  working 
under  considerable  pressure  to  prepare  for  the  com- 
ing examinations.  Ambition  to  excel  was  very  gen- 
eral, and  increased  the  high  tension  characteristic 
of  the  class  as  a  whole.  It  is  possible  that  over- 
stimulation had  much  to  do  with  their  condition  of 
underweight  and  it  is  probably  significant  that  58% 
were  borderline  cases  averaging  less  than  10% 
underweight. 

In  providing  for  these  children  the  school  had  not 
followed  the  usual  rapid  advancement  plan  by  whicb^ 
gifted  pupils  are  put  through  the  standard  curric 
ulum  in  the  shortest  possible  period.  The  attempt 
had  been  rather  to  broaden  the  school  experience  for 
those,  who  by  reason  of  superior  ability  could  best 
afford  time  for  additional  activities,  and  could  be 
expected  to  profit  most  from  them.  A  careful  can- 
vass of  neighborhood  facilities  had  resulted  in  secur- 
ing for  them  special  opportunities  for  library,  play- 
ground and  gymnasium  activities,  and  instruction 
in  music  and  drawing.  The  usual  school  discipline 
was  considerably  relaxed  in  the  conduct  of  their 
classes,  and  their  attitude  toward  every  new  interest 
and  opportunity  that  was  secured  for  them,  was  one 
of  eager  participation.  Thus  there  had  been  much 
in  their  previous  experience  to  prepare  them  for 


32  HEALTH  EDUCATION 

benefiting  from  the   suggestions   of  the  nutrition 
class. 

Physical  Care 

EXAMINATION  AND  DIAGNOSIS 

Every  child  enrolled  in  the  class  was  given  a  care- 
ful stripped  examination  by  one  of  the  physicians 
to  insure  correct  diagnosis  and  the  prescription  of 
treatment  if  conditions  of  disease  were  found  to  ex- 
ist, and  to  discover  indications  of  physical  defects 
calling  for  the  advice  and  treatment  of  a  specialist. 
Local  legislation  required  that  special  permission 
from  the  parents  must  be  obtained  in  every  case 
before  the  stripped  examination  could  be  made,  and 
this  provision  was  always  carefully  followed.  The 
nutrition  worker  secured  the  necessary  permissions 
and  urged  the  attendance  of  one  of  the  parents  at 
the  examination  in  the  hope  of  enlisting  home  inter- 
est and  cooperation  as  far  as  possible  from  the  start. 

The  efficiency  fetish  which  plays  so  important  a 
part  in  public  school  thinking  to-day,  is  only  too 
likely  to  exert  an  undue  influence  on  any  program 
demanding  the  amount  of  individualization  entailed 
by  the  nutrition  class.  Even  our  workers,  who  were 
under  no  necessity  for  observing  standards  other 
than  thoroughness,  and  were  free  to  expend  time  and 
care  as  the  necessity  of  the  individual  required,  felt 
keenly  at  first  the  desirability  of  making  the  experi- 
ment "efficient"  from  the  school  board  viewpoint 
by  limiting  the  time  and  effort  expended  to  out- 
standing essentials,  in  the  belief  that  the  amount 
of  time  and  work,  and  the  consequent  number  of 
workers  demanded,  must  be  limited,  so  far  as  poe- 


THE  INITIAL  PROGRAM  33 

sible,  in  order  to  commend  the  undertaking  to  the 
school  as  a  practical  one.  As  experience  increased, 
however,  and  our  workers  became  better  aware  of 
the  complex  factors  involved,  the  fallacy  of  confus- 
ing expedition  with  efficiency  became  more  and  more 
apparent.  The  time  required  for  the  examinations 
was  found  to  average  from  twenty  minutes  to  a  half 
hour. 

THE  CORRECTION  OF  DEFECTS 

Naso-Pharyngeal  Obstructions. — Children  who  ap- 
peared to  be  suffering  from  physical  defects  bear- 
ing in  any  way  on  the  nutritional  processes  were 
taken  by  the  nutrition  worker  to  one  of  the  available 
clinics  for  re-examination  by  a  specialist.  Naso- 
pharyngeal obstructions  were  the  chief  concern,  as 
the  presence  of  tonsil  and  adenoid  growths  definitely 
reduces  the  underweight's  ability  to  gain,  and  the 
effect  of  their  removal  has  been  aptly  characterized 
as  rendering  him ' '  free  to  gain. ' '  The  ideal  program 
is  therefore,  to  have  all  cases  recommended  for 
operation  treated  at  as  early  a  date  as  possible  after 
the  formation  of  the  class.  The  attempt  to  secure 
these  operations  for  children  needing  them  involved 
much  expenditure  of  time  and  effort  throughout  the 
entire  period.  It  was  generally  difficult  to  persuade 
the  parents  of  the  necessity  for  such  treatment,  and 
as  the  facilities  afforded  by  the  city  hospitals  were 
limited,  operations  had  often  to  be  delayed  after  the 
parents'  permission  had  been  secured.  Both  Belle- 
vue  and  the  Post-Graduate  Hospital  treated  cases 
for  us.  In  the  five  classes  organized  during  this  first 
term,  69  children,  or  QQ%  of  the  entire  number  en- 


34  HEALTH  EDUCATION 

rolled  were  recommended  for  removal  of  tonsils  or 
adenoids  or  both,  and  operations  were  secured  for 
only  20  children,  or  29%  of  the  number  needing 
them.  In  the  majority  of  cases  the  treatment  was 
delayed  until  the  term  was  considerably  advanced. 

Dental  Caries. — Second  in  importance  was  the 
treatment  or  removal  of  carious  teeth.  No  such 
obvious  results  in  weight  increase  attend  the  remedy- 
ing of  this  type  of  defect  as  follow  the  removal  of 
tonsils  and  adenoids.  It  was,  however,  always  given 
an  important  place  in  our  program,  as  an  essential 
of  any  general  health  program  where  preventive  as 
well  as  corrective  work  is  the  aim.  Eighty-eight  of 
our  children  out  of  the  total  105  were  persuaded  to 
undergo  examination  by  the  dentist  and  of  these,  63 
were  found  to  have  from  1  to  12  carious  teeth.  Treat- 
ment progressed  slowly  owing  to  the  indifference  of 
many  parents,  and  the  limited  clinic  facilities.  The 
Stuyvesant  Clinic  and  the  Twenty-Third  Street 
Clinic  both  treated  dental  cases  for  us. 

Eye  Strain. — Examination  for  eye  refraction  was 
given  in  a  few  cases  by  request  of  the  nutrition 
workers,  but  in  general  our  staff  did  not  assume 
responsibility  for  this  type  of  defect  as  the  Board  of 
Health  Eye  Clinic,  located  in  the  building,  provided 
excellent  facilities  for  the  children  of  the  school.  A 
strong  prejudice  against  glasses,  however,  existed 
in  the  homes  of  the  community  and  was  shared  by 
the  children.  Even  after  purchasing  glasses  few 
could  be  persuaded  to  wear  them  regularly  in  spite 
of  strenuous  efforts  on  the  part  of  the  nutrition 
worker  and  the  class  teacher  to  bring  this  about. 


THE  INITIAL  PROGRAM  35 

Cooperation  of  the  Home 

CONTKOL  OF  THE  ENVIRONMENT 

The  educational  features  of  the  nutrition  class 
may  be  said  to  begin  with  the  school  and  home  en- 
vironment, and  such  opportunities  as  they  afford  for 
experience  leading  to  proper  intake  of  food,  better 
digestion  and  increased  assimilation.  If  children 
are  to  cooperate  in  a  program  of  health  experiences, 
certain  conditions  as  to  food,  eating  habits,  fresh 
air,  rest  and  sleep  must  be  provided.  How  far  the 
homes  of  the  community  could  be  enlisted  to  make 
necessary  changes  in  customary  habits,  and  how  far 
they  would  be  found  able  to  do  so,  were  therefore 
points  of  particular  interest  and  importance  for  the 
experiment.  By  visits  of  the  nutrition  worker  and 
the  attendance  of  the  parents  at  the  weekly  sessions 
of  the  class,  we  hoped  to  secure  the  necessary  co- 
operation of  the  home  in  providing  the  following 
conditions : 

Food. — Adequate  caloric  intake  averaging  2000 
calories  a  day. — While  individual  needs  must  de- 
termine variation  in  the  figure,  it  was  believed  this 
amount  would  be  found  to  constitute  an  increase 
over  what  the  average  child  was  receiving. — Mid- 
morning  and  mid-afternoon  lunches,  designed  to  add 
from  250  to  300  calories  to  the  amount  received  at 
the  usual  meals. — These  lunches  were  not  to  consist 
of  foods  like  sweets  calculated  to  take  away  the 
appetite  for  the  regular  meal.  They  were  advised 
by  Dr.  Emerson  on  the  theory  that  undernourished 
children,  like  invalids,  will  assimilate  better  if  food 
is  taken  in  smaller  quantities  at  briefer  intervals. 


36  HEALTH  EDUCATION 

Diet. — To  increase  the  caloric  intake,  milk  and  ce- 
reals were  recommended,  as  the  best  foods  by  which 
the  home  table  could  be  supplemented  for  the  under- 
weight child,  with  the  least  disturbance  to  family- 
preferences  and  eating  habits.  The  elimination  of 
tea  and  coffee,  and  of  any  other  stimulants  the  home 
table  might  afford,  was  especially  stressed,  as  well 
as  the  necessity  for  an  adequate  breakfast. 

Prevention  of  Over-Fatigue. — A  half  hour  rest 
period  before  the  mid-day  meal  and  avoidance  of  un- 
due physical  activity,  as  roller-skating  and  ball- 
playing  for  protracted  periods,  and  the  need  for 
proper  hours  of  sleep  with  open  windows,  were  es- 
pecially emphasized. 

Personal  Hygiene. — In  addition,  the  intelligent 
supervision  of  the  home  was  sought  in  habits  of  eat- 
ing, bathing  and  elimination. 

HOME  VISITING 

Permission  for  the  stripped  physical  examination 
and  the  gathering  of  information  concerning  birth 
and  infancy,  previous  diseases,  and  general  health 
habits,  with  other  social  data  regarding  members  of 
the  family  was  the  primary  cause  of  home  visiting 
by  the  nutrition  worker,  and  required  at  least  two 
visits  to  each  family.  Arrangements  for  securing 
the  removal  of  physical  defects  when  recommended 
necessitated  further  visits.  During  this  first  school 
term,  however,  a  definite  attempt  was  made  to  limit 
the  home  visiting  and  to  make  the  necessary  contacts 
with  the  parents  through  their  attendance  at  the 
weekly  class  sessions.  This  was  especially  urged  by 
Dr.  Emerson,  who  was  accustomed  to  securing  the 


THE  INITIAL  PROGRAM  37 

attendance  of  mothers  at  hospital  classes,  and  was 
anxious  to  develop  the  school  nutrition  class  with 
as  small  a  staff  as  was  consistent  with  the  demands 
of  the  situation.  But  the  attempt  to  secure  the 
mothers'  attendance  at  the  weekly  class  meetings 
was  never  very  successful.  The  aversion  of  these 
foreign  mothers  to  leaving  their  homes  for  any  pur- 
pose outside  the  usual  one  of  shopping  and  market- 
ing is  very  great,  and  their  attendance  as  secured 
by  the  hospital  clinic,  is  of  itself  indicative  of  their 
conviction  that  the  children  concerned  are  really  ill. 
Where  this  is  not  obvious,  it  is  often  a  slow  process 
to  convince  either  parent  that  any  extra  attention 
is  needed. 

Cooperation  of  the  School 

THE  EYE  CLINIC  KOOM 

Through  the  courtesy  of  the  Board  of  Health  we 
were  allowed  to  conduct  our  work  in  the  one  avail- 
able spot  the  crowded  school  building  afforded. 
This  was  the  eye  clinic  room,  a  class-room  that  had 
been  set  aside  for  that  purpose.  Sessions  of  the 
clinic  were  held  here  every  morning,  but  after  twelve 
the  room  was  used  only  by  the  clinic  nurse  who 
worked  at  her  desk,  leaving  the  rest  of  the  room  free 
for  the  activities  incident  to  the  nutrition  classes. 
Our  equipment  consisted  of  a  Buffalo  scale,  a  stadiom- 
eter,  two  screens,  an  examining  table,  and  a  cabinet 
file  for  records.  Except  for  these,  and  the  eye 
clinic  desk  and  vision  charts,  the  room  presented  no 
special  features  of  equipment.  Settees  replaced  the 
customary  forms  and  desks,  and  offered  certain  ad- 
vantages in  rearranging  the  room  for  our  purposes. 


38  HEALTH  EDUCATION 

These,  with  blackboards,  and  a  table  and  chair  for 
the  teacher,  constituted  the  furnishings.  A  good 
north  light  was  secured  from  large  windows  along 
one  side.  When  the  classes  met  the  children's  charts 
were  ranged  against  the  blackboards  in  the  back  of 
the  room  for  discussion.  The  screens  were  used 
when  physical  examinations  were  made  or  stripped 
weights  taken. 

How  far  the  work  of  the  eye  clinic  may  have  been 
embarrassed  or  impeded  by  this  partnership  ar- 
rangement, we  were  never  informed,  for  at  all  times 
our  work  and  our  workers  received  the  utmost  con- 
sideration and  sympathy  both  from  Dr.  Eobert 
Kahn,  the  oculist,  and  from  Mrs.  B.  G.  Eeid,  the 
nurse.  If  our  own  workers  felt  seriously  the  restric- 
tions imposed  by  the  situation  we  cannot  feel  very 
sanguine  over  the  effect  of  our  strenuous  program 
on  theirs.  At  no  time  was  it  possible  for  the  room 
to  be  given  over  entirely  to  the  nutrition  work,  and 
the  nutrition  staff  was  always  conscious  of  the  neces- 
sity for  conducting  its  work  of  weighing  and  measur- 
ing, checking  up  and  recording,  with  the  least  pos- 
sible disturbance  to  the  others.  During  the  first  term 
when  Dr.  Emerson's  visits  were  frequent  and  his  lim- 
ited time  perforce  divided  among  several  classes, 
preparation  for  the  class  instruction  had  to  be  made 
even  before  Dr.  Kahn  had  finished  his  regular  clinic 
sessions.  When  weights  were  taken  the  combined 
requirements  imposed  on  the  nutrition  worker  for 
accuracy  in  the  records,  quiet  in  a  group  of  restless 
boys,  and  expedition,  that  the  children  might  be  re- 
turned to  their  class-rooms  with  the  least  possible 
loss  of  time,  rendered  the  work  particularly  trying. 


THE  INITIAL  PROGRAM  39 

The  difficulty  of  taking  stripped  weights  under  these 
conditions  will  be  apparent,  but  the  regular  weekly 
weight-taking  without  shoes  was  in  itself  a  sufficient 
problem.  The  first  grade  boys  at  the  beginning  of  the 
term  could  not  take  off  their  shoes  nor  put  them  on 
without  assistance,  and  for  all  ages  it  was  apt  to  be  a 
relatively  slow  process.  Shoe  laces  with  frayed  ends 
were  common,  and  they  were  often  wet  and  knotted. 
Shoes  and  stockings,  too,  were  frequently  water- 
soaked.  Nor  could  the  littlest  boys  manage  to  pull 
off  and  on  the  tight-fitting  sweaters  that  were  uni- 
versally popular. 

The  location  of  the  room,  overlooking  the  play- 
ground and  next  to  the  metal  workshop,  rendered  the 
work  of  recording  particularly  difficult  because  of 
noises  from  outside,  especially  the  shouts  and  cries 
of  the  second  session  children  gathered  about  the 
doors  waiting  for  their  classes  to  begin.*  To  add 
to  the  responsibility  of  these  sessions  rapid  dismis- 
sal signals  (fire  alarm)  which  could  not  be  disre- 
garded were  frequent,  and  visitors  came  at  all  times 
to  observe  our  methods.  It  mil  be  evident  that 
whatever  educational  possibilities  the  experience  of 
weight  and  height-taking  might  in  itself  have  af- 
forded, were  seriously  impaired  by  the  conditions 
under  which  these  activities  had  to  be  conducted. 

CONTROL    OF    THE    ENVEEONMENT 

In  addition  to  furnishing  headquarters  for  the 
work  and  facilities  for  the  physical  examinations, 
weekly  weight-taking  and  class  sessions,  the  school 
was  asked  to  cooperate  in  the  attempt  at  better  con- 

♦  See  p.  112. 


40  HEALTH  EDUCATION 

trol  of  the  environment.  Compliance  with  Dr.  Emer- 
son's  request  for  shorter  hours  of  work  and  open- 
window  rooms  for  all  the  nutrition  class  pupils, 
seemed  quite  beyond  the  possibility  of  the  situation 
except  in  the  case  of  a  few  children,  11  in  all,  who 
because  of  pre-tubercular  or  anaemic  condition  were 
enrolled  in  one  of  the  school's  regular  open-air 
classes.  Opportunities  for  additional  food  intake 
and  for  rest  periods  were  arranged  during  school 
hours  but,  partly  for  purposes  of  comparison,  partly 
because  it  was  found  impossible  to  secure  like  op- 
portunities for  all,  the  school  program  was  varied 
for  the  different  groups.  Three  of  the  classes  were 
given  a  mid-day  dinner  with  a  value  of  approxi- 
mately 1000  calories.  For  four  classes  a  special  mid- 
morning  lunch  was  arranged.  Three  classes  had 
opportunities  for  a  half  hour  rest  during  the  school 
session,  and  the  little  group  in  the  open-air  class 
received  the  regular  mid-morning  lunch  provided  in 
all  the  open-air  class-rooms.  They  had  in  addition 
the  special  facilities  of  the  open-air  rooms  for  rest- 
taking  and  fresh  air,  as  well  as  a  lighter  program 
of  work.  The  group  of  20  boys  from  the  fifth  grade, 
received  only  the  mid-day  dinner  and  was  not  in- 
cluded in  the  general  program  of  physical  care  and 
instruction.  This  group  therefore  in  some  particu- 
lars resembled  a  control  group.  The  chief  considera- 
tion in  making  these  special  provisions  for  different 
classes  was  a  desire  to  determine  the  relative  value  of 
school  feeding  in  the  program.  It  was  through  the 
generous  cooperation  of  Christodora  House  and  of 
the  New  York  School  Lunch  Committee  that  we  were 


THE  INITIAL  PROGRAM  41 

able  to  secure  the  requisite  facilities  for  this  part  of 
the  work. 

MID-MORNING   LUNCHES 

These  were  supplied  and  served  by  Christodora 
House  to  the  children  of  the  sixth  grade,  seventh 
grade,  first  grade,  and  Terman  classes,  and  con- 
sisted of  hot  cocoa  with  crackers  or  bread  and  butter. 
The  children  enrolled  in  these  groups  went  next  door 
to  the  settlement  to  get  this  lunch  beween  ten  and 
eleven  o'clock  every  morning  during  ''out  time" 
periods  afforded  by  the  school's  double  session 
schedule.*  As  the  school  was  entirely  without  lunch 
room  or  domestic  science  equipment  this  appeared 
to  be  the  only  arrangement  possible.  It  involved 
much  extra  time  and  loss  of  energy,  especially  in 
cold  or  stormy  weather.  Many  of  the  children  too 
were  embarrassed  and  rebellious  over  other  cir- 
cumstances attending  it.  The  necessity  of  going 
for  it  when  the  other  children  did  not,  rendered 
them  conspicuous,  and  ' '  different ' '  from  their  class- 
mates who  did  not  fail  to  taunt  them  over  their 
peculiarities.  Thus  many  came  only  under  protest 
after  being  ''rounded  up"  by  the  nutrition  workers 
and  "cutting"  was  frequent.  Moreover,  as  no 
charge  was  made  for  the  lunch,  the  stigma  of 
"charity  food"  was  attached  to  it  at  first,  and  many 
parents  objected  until  its  nature  and  purpose  was 
fully  explained  to  them.  These  difficulties  became 
less  as  time  progressed  and  most  of  the  children 
came  to  understand  and  appreciate  the  significance 
of  the  nutrition  program.    The  luncheon  itself  was 

* ' '  Out  time, ' '  periods  when  the  children  are  not  in  their  class- 
rooms but  are  under  supervision. 


42  HEALTH  EDUCATION 

always  acceptable  to  them  and  taken  with  apparent 
enjoyment,  even  by  those  who  protested  most  vigor- 
ously over  going  for  it. 

MID-DAY  DINNER 

The  mid-day  dinner  was  supplied  by  the  School 
Lunch  Committee  and  delivered  at  Christodora 
House  where  service  and  supervision  were  furnished. 
Sixty-five  children  from  the  Terman,  the  sixtli  grade 
and  the  fifth  grade  groups  received  this  meal.  As 
the  dining  room  capacity  at  Christodora  House  was 
limited  to  35,  the  children  were  served  in  two  groups. 
The  menus  were  planned  to  provide  1000  calories  and 
to  broaden  dietary  habits  with  respect  to  vegetables, 
milk  dishes,  and  cooked  fruits.  This  deliberate  at- 
tempt to  supplement  the  deficiencies  of  the  home 
dietary  and  develop  a  taste  for  new  dishes,  however 
excellent  and  important  from  the  theoretical  stand- 
point, presented  very  serious  practical  difficulties.  In 
addition  to  the  aversion  felt  by  most  children  for  un- 
accustomed dishes,  the  carefully  inculcated  prejudice 
of  the  Jewish  child  against  strange  foods,  the  fear 
that  they  may  not  be  kosher,  had  to  be  reckoned 
■v\dth.  This  fear  conditions  the  attitude  of  the  Jew- 
ish child  toward  any  unaccustomed  food  and  greatly 
increases  the  difficulty  of  persuading  him  to  eat  new 
dishes.  The  high  seasoning  to  which  his  home  cook- 
ing accustoms  him  presents  another  serious  problem. 
Bland  and  relatively  delicate  flavors  are  unappetiz- 
ing to  palates  demanding  pickles,  mustard  and  spice 
as  a  matter  of  course.  In  addition  it  must  be  re- 
membered that  few,  if  any  of  these  children  could 
be  classed  as  ** hungry  cases,"  and  both  the  Terman 


THE  INITIAL  PROGRAM  43 

and  sixth  grade  groups  were  receiving  mid-morning 
luncheon  in  addition  to  dinner.  Under  the  circum- 
stances it  is  not  surprising  that  the  children  were 
indifferent  to  the  dinner.  Indeed,  many  of  them  were 
never  persuaded  to  eat  much,  although  as  time  pro- 
gressed the  general  attitude  was  better,  as  in  the 
case  of  the  attendance  at  the  mid-morning  luncheon. 
In  the  beginning  there  was  much  disorder  and  even 
*' rough  house"  in  the  dining  room.  The  intervals 
occasioned  by  the  Easter  vacation  and  the  Jewish 
holidays  at  Passover  broke  up  the  continuity  of  the 
experiment,  and  during  June,  after  the  children  had 
really  begun  to  take  the  meal  with  some  degree  of 
satisfaction,  the  hot  weather  made  serious  inroads 
on  appetite.  Some  concessions  to  the  children's 
tastes,  which  the  workers  in  charge  felt  could  be 
made  without  sacrificing  the  nutritional  and  educa- 
tional value  of  the  meal,  were  made.  Such  dishes 
as  rice  pudding  and  custards,  for  example,  were  given 
up,  and  desserts  of  cooked  fruits  substituted.  Two 
sample  menus  reflecting  this  modification  follow; 
as  has  been  previously  noted,  they  were  planned  to 
supplement  deficiencies  of  the  home  dietary,  not  as 
model  balanced  meals.* 

Eice  Soup   (with  milk)  Potato  Salad 

Mashed  Potato  and  Turnip  Eye  Bread  and  Butter 

Eye  Bread  and  Butter  Prune  Pudding 

Baked  Apples  Cocoa 

REST  PERIODS 

These  were  taken  in  the  gymnasium  at  Christo- 
dora  House  for  a  half  hour  before  the  luncheon 
period.  The  sixth  and  seventh  grade  groups  were 
required  to  take  this  rest  period.     The  Terman 

*  See  Appendix  D. 


44  HEALTH  EDUCATION 

groups  were  advised  to  take  it,  and  many  of  them 
did  so.  The  children  lay  on  the  floor  each  wrapped 
in  a  blanket.  There  was  always  more  or  less  diffi- 
culty in  securing  cooperation,  especially  from  the 
older  boys,  and  the  task  of  supervising  the  rest 
period  was  not  an  easy  one.  The  shouts  and  cries 
of  their  class-mates  at  play  in  the  square  outside 
could  be  plainly  heard,  and  this  made  resting  seem 
even  more  *' babyish"  than  it  already  appeared  to 
restless  spirits.  Occasionally  one  or  two  of  the 
more  obstreperous  would  decide  to  endure  it  no 
longer,  and  would  suddenly  cut  out  of  the  room,  and 
escape  to  freedom.  In  spite  of  these  disturbing  ele- 
ments, there  is  no  doubt  that  the  children  whose 
interest  had  been  enlisted,  succeeded  in  getting  bene- 
fit from  the  period,  and  learned  to  lie  quietly  relaxed 
without  being  seriously  disturbed  by  their  more  rest- 
less neighbors. 

Enlistment  of  the  Child's  Cooperation 

INDIVIDUAL,  INSTRUCTION 

To  secure  the  second  half  of  the  educational 
program,  the  cooperation  of  the  child  within  his  en- 
vironment, both  individual  and  class  instruction 
were  provided.  Following  the  weekly  measurements 
a  brief  interview  between  pupil  and  nutrition 
worker  took  place.  Each  child  was  given  a  specially 
devised  booklet*  containing  a  table  of  100  calorie 
portions  of  common  foods  in  which  to  record  his 
food  intake  for  48  hours.  He  was  asked  to  make  a 
list  of  the  actual  food  taken ;  slices  of  bread,  ounces 

*  Emerson,   Wm.   R.   P.,   A    Record   Boole   for   Measured   Feeding, 
Pub.  No.  3.     Nutrition  Clinics  for  Delicate  Children,  Boston,  Mass. 


THE  INITIAL  PROGRAM  45 

of  milk,  tablespoonfuls  of  cereal,  etc.  This  48-ho-ar 
record  was  returned  each  week  and  the  caloric  in- 
take figured  by  the  nutrition  worker. 

Further  data  were  obtained  by  the  nutrition 
worker  on  the  entire  week's  record  with  regard  to 
observation  of  the  prescribed  program,  rest  periods, 
lunches,  hours  of  sleep,  drinking  of  tea  and  coffee, 
water  at  meals,  fresh  air,  breakfast  habits,  rapid 
eating,  exercise,  fatigue,  colds,  clothing  and  any 
other  facts  of  significance  in  the  week's  history. 
Notes  made  at  the  time  of  this  interview  were  used 
later  as  a  basis  for  discussion  of  the  individual 
charts  at  the  class  meeting.  These  charts  were  de- 
signed to  record  the  outstanding  features  of  the 
week's  history.  Gain  or  loss  of  weight,  number  of 
rest  periods,  mid-session  lunches,  use  of  tea  and 
coffee,  and  caloric  intake  as  well  as  progress  in  the 
correction  of  defects,  were  graphically  indicated  by 
this  means.* 

CLASS  INSTRUCTIOlSr 

During  the  first  term  the  several  nutrition  classes 
met  for  weekly  half  hour  class  sessions  in  the  eye 
clinic  room.  As  several  classes  of  the  same  grade 
exist  in  P.  S.  64,  each  of  the  nutrition  groups  was 
recruited  from  children  belonging  in  more  than  one 
class-room.  Thus  many  members  were  strangers  to 
each  other  and  this  fact,  together  with  the  unaccus- 
tomed room  and  special  teachers,  was  partly  respon- 
sible for  the  formality  and  restraint  which  char- 
acterized the  class  sessions  at  first.  The  average  age 
range  was  sufficiently  limited  to  make  a  similar  pro- 

*  See  Appendix  C. 


46  HEALTH  EDUCATION 

cedure  feasible  for  all  the  groups  with  the  exception 
of  the  first  grade.  For  them,  however,  the  type  of 
class  instruction  employed  was  quite  unsuited  and 
beyond  their  ability  to  comprehend.  Though  they 
did  acquire  a  conception  of  the  chart  and  its  meaning 
and  a  few  outstanding  facts  concerning  health  habits, 
relatively  little  was  accomplished  during  the  term 
toward  developing  methods  better  suited  to  their 
years.  At  first  the  conduct  of  the  class  devolved  on 
the  physician,  Dr.  Emerson  at  the  beginning,  and 
later  Dr.  Henry  J.  Schreiber  who  assisted  him.  The 
individual  charts  were  arranged  on  the  wall  facing 
the  class,  in  the  order  of  greatest  gain  for  the  week, 
and  each  child  was  seated  before  his  own  chart. 
Thus  the  distinction  of  "head"  and  ''foot"  of  the 
class  was  made  prominent,  and  any  mothers  pres- 
ent were  seated,  each  behind  her  oaati  child,  with 
the  view  of  further  emphasizing  the  idea  of  success 
and  failure.  The  subject  matter  of  the  lessons  was 
chiefly  derived  from  consideration  of  the  individual 
charts,  and  the  conclusions  to  be  drawn  from  the 
relative  gain  and  loss  they  indicated.  Interpreta- 
tions were  supplemented  by  the  nutrition  worker's 
notes  made  at  the  time  of  the  weekly  weight  taking. 
There  was  also  discussion  of  related  informational 
matter.  Nutritional  standards,  the  significance  of 
measured  feeding,  the  value  of  milk  and  cereals,  the 
bad  effects  of  tea  and  coffee,  food  habits  and  general 
health  habits  were  thus  presented  to  the  children's 
attention  in  their  direct  bearing  on  their  own  phy- 
sical welfare.  Special  deductions  and  recommenda- 
tions in  regard  to  individual  children  resulting  from 
this  class  discussion  were  noted,  and  repeated  later 


THE  INITIAL  PROGRAM  47 

to  the  child  or  his  mother  by  the  nutrition  worker. 

It  will  be  evident  that  little  opportunity  was 
afforded  the  physicians  for  special  planning  of  the 
day's  discussion  in  advance,  as  they  were  under  the 
necessity  of  receiving  the  material  for  discussion 
from  the  nutrition  worker  at  the  time  the  class  as- 
sembled. Such  a  situation  invariably  results  in 
much  repetition,  and  relatively  little  opportunity  for 
developing  the  possibilities  of  the  subject  matter.  It 
is  the  usual  procedure  where  the  class  method  has 
been  adopted  for  clinic  use,  and  this  first  term  might 
well  be  called  the  "clinic  stage"  of  our  class  proce- 
dure. The  problems  arising  as  well  as  the  techniques 
employed  are,  we  believe,  fairly  characteristic  of  the 
usual  clinic  experience.  The  limitations  disclosed, 
so  far  as  they  concern  the  enlistment  of  cooperation 
from  the  children,  were  inherent  in  the  situation  and 
arose  first  from  the  unequal  physical  endowment 
of  individuals  and  consequent  inability  to  accom- 
plish results  in  direct  ratio  with  effort,  secondly 
from  the  inequality  of  home  facilities  for  coopera- 
tion which  contributed  in  increasing  measure  to  the 
workers'  sense  of  injustice  toward  certain  children. 
In  addition,  there  was  the  inaccuracy  of  home  rec- 
ords and  the  attendant  difficulty  of  exercising  proper 
judgment  in  regard  to  a  child's  veracity.  Every  at- 
tempt on  the  school's  part  to  secure  data  from  the 
home  is  more  or  less  subject  to  this  difficulty  and 
the  possibility  of  encouraging  inaccuracy  or  even 
conscious  deceit  is  a  serious  one. 

In  addition  to  these  difficulties  others  arising  from 
faulty  techniques  should  be  mentioned.  The  use  of 
competition  was  certainly  questionable  in  view  of  the 


48  HEALTH  EDUCATION 

fact  evident  to  all,  that  often  conscientious  children 
failed  to  gain  as  much  as  others  who  were  careless 
or  lacking  in  interest.  The  discouragement  felt  by 
the  individual  who  could  not  approximate  his  normal 
weight  line,  was  only  increased  by  the  introduction 
of  the  competitive  idea,  and  the  arrangement  of  the 
charts  each  week  in  the  order  of  weight  increase  with 
the  best  record  at  the  "head  of  the  class."  The 
appeal  to  future  benefits  to  be  secured,  as  a  "place 
on  the  ball  team  in  high  school,"  was  also  employed, 
although  generally  recognized  by  the  modem  school 
of  teaching  as  insufficient  for  enlisting  continued 
cooperation  from  the  average  child. 

Half  an  hour  for  discussion  of  the  kind  involved, 
in  a  class  of  20  to  25,  led  to  hasty  and  occasionally 
to  false  deductions  as  to  causes  of  failure,  the  injus- 
tice of  which  was  deeply  felt  by  the  children  con- 
cerned. But  the  didacticism  and  formality  of  the 
class  procedure  effectually  prevented  remonstrance 
or  explanation  in  such  cases,  especially  as  the  center- 
ing of  attention  on  the  chart  made  for  self-con- 
sciousness. The  impressions  of  a  teacher  who 
made  a  number  of  visits  to  the  several  classes  may 
well  be  quoted  here :  ' '  The  children  clearly  showed 
self-consciousness;  their  attitude  was  a  listening 
one ;  they  seldom  had  a  chance  to  say  anything  except 
in  reply  to  direct  questions.  They  were  talked  to 
rather  than  with;  the  latter  takes  more  time,  but 
does  it  not  make  for  a  greater  feeling  of  responsi- 
bility, less  direct  adherence  to  direction  and  more 
thinking  out,  less  mere  cure  and  more  growth  of 
judgment?  Moreover,  much  of  the  talk  is  for  each 
child  a  repetition  of  what  the  nutrition  worker  has 


THE  INITIAL  PROGRAM 


49 


already  gone  over  with  him,  when  she  weighed  and 
measured  him  and  made  his  diet  list.  It  must  seem 
to  him  unimportant,  except  to  make  him  conspicuous, 
with  the  attention  of  the  doctor  and  others  focussed 
on  him.  Do  we  wish  him  to  like  this?  The  social 
element  seems  unnecessarily  left  out.  Should  not 
public  discussion  be  reserved  for  topics  of  common 
interest,  topics  of  an  interest  that  is  clearly  common 
to  all  of  them,  something  that  cannot  seem  an  ex- 
ploitation of  individual  ailments?  After  all  it  is  not 
a  difference  of  subject,  but  of  approach.  Health 
rather  than  cure  should  be  the  function  of  a  class- 
room talk.*' 

Statistical  Data  and  Interpretations 

GROUP  SELECTION 

Eight  hundred  children  of  the  four  grades  selected 
were  weighed  and  measured  with  the  results  shown 
in  Table  I: 


TABLE  I* 

ReSTTLTS   of   MEAStTREMENTS,   CHILDREN   OP   FoUR   GRADES 


Grade 
VII 

Grade 
VI 

Grade 
V 

Grade 
I 

Total 

Total  number 

7%  or  more  imderweight. . . 
Per  cent  underweight 

173 
25 
14.4 

245 
39 
15.9 

127 

27 
21.3 

255 
43 
16.9 

800 
134 
16.8 

•  The  computations  of  statistical  data  and  charts  appearing  in  this 
chapter  and  the  next  were  made  by  Dr.  David  Mitchell  and  pub- 
lished in  The  Pedagogical  Seminary,  March,  1919  and  March,  1920. 
They  are  reproduced  here  by  courtesy  of  the  editors. 


50 


HEALTH  EDUCATION 


At  no  time  was  the  attempt  made  to  weigli  and 
measure  the  entire  school  population,  as  P.  S.  64 
enrolls  approximately  3000  pupils  and  from  the 
first  it  was  our  purpose  to  work  intensively  with  a 
relatively  small  number  of  children.  In  so  far  as 
these  four  grades  may  be  considered  to  represent  a 
cross-section  of  the  school  population  at  the  begin- 
ning of  our  work  in  February,  1918,  the  above  aver- 
age, 16.8%,  approximates  the  average  of  children 
7%  or  more  underweight  throughout  the  school  at 
that  time. 

The  children  of  the  Terman  and  open-air  group 
are  not  included  in  the  above  cross-section,  as  they 
cannot  be  considered  representative  of  the  average 
since  they  were  drawn  from  two  specially  selected 
groups.  Eesults  of  the  initial  weight-taking  in  these 
two  groups  and  comparison  with  the  results  in  the 
regular  grades  are  shown  in  Table  II. 


TABLE  II  * 

Results  op  Measubements,  Special  Classes  and  Regular 
Grades 


Terman 

Open-air 

Grades 

Total 

Total  number 

69 
19 
27.5 

25 

7 
28 

800 
134 
16.8 

894 

7%  or  more  underweight 

Per  cent  underweight 

160 
17.7 

*  For  distribution  table  of  the  total  niunber  weighed  see  Appen- 
dix A, 


THE  INITIAL  PROGRAM 


61 


COMPAKATIVE  RESULTS   IX    WEIGHT   INCREASE 

Of  the  total  160  children  found  7%  or  more  Tinder- 
weight,  105  were  enrolled  in  nutrition  classes. 
Twenty  more  were  included  in  the  group  of  fifth 
grade  boys  given  the  mid-day  dinner.  The  results 
of  the  experiment  in  terms  of  weight  increase  for 
the  several  groups  after  nineteen  weeks  are  given 
in  Table  III. 


TABLE   III  * 

Comparative  Weight  Increase   of  the  Several  Groups  after 

19  Weeks 


Nn 

Pounds 

Normal 

Net 
Gain 

Percentage 

Group 

Enrolled 

Total 

Expected 

of  Normal 

Gain 

Gain 

Gain 

7th  grade 

23 

72 

64.8 

7.2 

111.1 

6th  grade 

28 

109 

89.9 

18.1 

120.1 

1st  grade 

26 

55.7 

40.5 

15.2 

137.5 

Terman 

17 

61.6 

43.2 

18.4 

142.6 

Open  air 

11 

105 

13.7 

23.4 

-  9.5 

59.1 

5th  grade 

20 

6 

23.2 

-17.2 

25.9 

*  The  estimates  of  normal  expected  gain  were  calculated  in  the 
accepted  way  from  the  average  yearly  increase  as  given  in  the  Burk- 
Boas  table  of  normal  weights.  That  is,  a  proportional  increase  for 
the  period  (19  weeks)  was  estimated  on  the  basis  of  a  supposed 
steady  increment  in  weight  from  month  to  mouth  throughout  the 
year.  Thus  if  the  normal  annual  increase  for  a  12  year  old  boy 
of  a  certain  height  is  8  pounds,  in  nineteen  weeks  he  would  be  ex- 
pected to  gain  approximately  3  pounds.  In  view  of  subsequent  find- 
ings as  to  seasonal  variation  in  weight  increase  (see  p.  127)  it  will 
be  apparent  that  the  normal  expected  gain  for  fractions  of  a  year 
cannot  be  so  simply  determined,  and  that  the  results  in  the  given 
tables,  except  for  the  total  number  of  pounds  gained,  have  been 
seriously  undercut.  They  are  included  here,  however,  because  they 
still  afford  a  basis  for  assessing  the  comparative  results  obtained  in 
the  different   groups. 


52 


HEALTH  EDUCATION 


Comparison  of  the  weight  increase  for  these 
groups  with  variations  in  their  several  programs  is 
shown  in  Table  IV. 

TABLE  IV  * 

Comparison  of  Variations  in  the  Several  Programs  and  Results 
IN  Weight  Increase 


Results  in 

Group 

Physi- 
cal 
Care 

Instruc- 
tion 

Rest 

Lunch 

Dinner 

Fresh 
Air 

Lighter 
Pro- 
gram 

per- 
centage 
of  Normal 
Gain 

Terman 

* 

* 

* 

* 

* 

X 

X 

142.6 

Ist  grade 

* 

* 

X 

* 

X 

X 

X 

137.5 

6th  grade 

* 

* 

* 

* 

* 

X 

X 

121.25 

7th  grade 

* 

* 

* 

* 

X 

X 

X 

111.1 

Open  air 

* 

* 

* 

* 

X 

* 

* 

51. 

5th  grade 

X 

X 

X 

X 

* 

X 

X 

25.9 

(*  =  Yes.     x  =  No.     ) 
INTEKPRETATIONS 

While  only  tentative  conclusions  are  possible 
owing  to  the  small  number  of  individuals  in  each  of 
the  groups  discussed,  certain  interpretations  can  be 
offered  in  connection  with  these  tables.  The  most 
striking  fact  recorded  is  the  apparent  failure  to 
secure  results  in  weight  increase  that  are  directly 
attributable  to  the  school  feeding  program.  From 
Table  IV  it  is  evident  that  some  children,  to  whom 
the  mid-day  dinner  of  1000  calories  was  served, 
gained  considerably  less  than  others  in  whose  pro- 
gram it  was  not  included.  While  the  greatest  aver- 
age percentage  of  gain  was  made  by  the  Terman 
class  who  received  both  mid-day  dinner  and  mid- 
morning  lunch,  the  average  gain  made  by  the  first 
grade  was  nearly  as  great,  yet  no  dinner  was  at- 
tempted for  them.    The  fifth  grade  children  whose 


THE  INITIAL  PROGRAM  53 

program  was  limited  entirely  to  the  mid-day  dinner, 
show  the  least  satisfactory  results,  as  they  lost 
weight  steadily  through  the  four  months  of  the 
experiment. 

These  results  are  not  surprising  in  view  of  the 
problems  attending  the  mid-day  dinner.  As  has 
been  already  indicated  (p.  42)  the  children  were 
afraid  of  unaccustomed  food  and  used  to  high  sea- 
soning. Thus  they  did  not  find  the  meal  appetizing 
and  they  were  not  hungry  enough  to  eat  what  they 
did  not  like.  Had  the  period  of  the  experiment  been 
a  longer  one,  a  greater  degree  of  cooperation  might 
have  been  secured  from  them  as  a  result  of  the  pro- 
gram of  instruction.  How  far  the  results  to  weight 
increase  would  have  been  augmented,  however,  re- 
mains a  speculation.  Aside  from  demonstrating 
some  practical  difficulties  of  a  school  feeding  pro- 
gram, our  results  for  the  mid-day  dinner  are  quite 
inconclusive. 

As  mid-morning  lunches  were  served  to  all  the 
children  with  the  exception  of  the  fifth  grade,  we 
must  look  to  other  factors  for  the  interpretation  of 
the  relative  gains  shown  by  Table  IV. 

The  distinguishing  feature  of  the  Terman  group 
is  its  intelligence  (measured  by  a  special  standard) 
and  this  may  be  supposed  to  have  made  the  instruc- 
tion given  it  more  effective.  An  intelligent  over- 
control  of  the  environment  by  adults  is  one  of  the 
goals  set  by  our  attempted  program.  To  such  an 
over-control  the  intelligent  self-control  of  the  Ter- 
man group  might  be  said  to  approximate.  The 
eager-minded  and  participatory  attitude  of  these 
children  toward  all  their  school  activities,  ensured 


54  HEALTH  EDUCATION 

better  cooperation  on  their  part  than  could  be  ob- 
tained from  children  of  the  regular  grades.  Thus 
intelligence  in  the  group,  or  in  direct  application  to 
the  control  of  the  group,  is  suggested  as  one  ex- 
planation of  the  satisfactory  results  they  achieved. 
It  is  also  probable  that  as  a  group  the  chief  causal 
factors  of  their  underweight  were  of  a  nature  cal- 
culated to  permit  ready  response  to  an  improved 
regime.  It  is  quite  possible  that  the  Terman  children 
were  underw^eight  largely  because  of  an  increased 
metabolism,  and  that  their  ability  to  respond  to  im- 
proved conditions  of  food  taking,  rest  and  fresh  air 
was  therefore  proportionately  better  than  that  of 
individuals  in  the  other  groups.* 

Second  only  to  the  gain  made  by  the  Terman  class 
is  the  record  of  the  first  grade  children,  yet  their  pro- 
gram included  only  the  provisions  for  physical  care 
and  instruction  and  was  considered  by  members  of 
the  staff  the  least  satisfactory  of  any  afforded. 
Because  the  program  of  instruction  was  ill-adapted 
to  their  age  period,  increased  necessity  for  co- 
operation from  the  home  was  felt  by  the  staff,  and 
therefore  much  greater  effort  was  made  to  interest 
the  mothers  and  secure  their  attendance  at  the  class 
sessions.  Our  efforts  were  reinforced  by  the  greater 
readiness  of  parents  to  maintain  intelligent  control 
and  lend  cooperation  to  special  efforts  on  behalf  of 
young  children.  Thus  better  environmental  control 
was  secured  for  this  group  than  we  were  able  to 
secure  for  the  others,  and  the  special  factor  of  in- 

*  See  Burnham,  Wm.  H.,  The  Metabolism  of  Childhood,  Pedagogical 
Seminary,  Dec,  1920,  pp.  304-322.  Where  the  hypothesis  is  pre- 
sented that  the  curve  of  learning  is  correlated  with  the  curve  of 
metabolism. 


THE  INITIAL  PROGRAM  55 

telligence  in  the  Terman  group  was  paralleled,  in 
the  case  of  the  first  grade,  by  the  factor  of  adult 
supervision.  In  addition,  we  must  consider  too,  the 
readier  response  of  little  children  to  conditions 
affecting  them  for  good  or  ill.  This  better  ability 
of  their  age  period  to  respond,  again  parallels  the 
probable  better  ability  to  respond  on  the  part  of  the 
Terman  group. 

Intelligent  control  of  the  environment  was  less 
easily  secured  for  the  children  of  the  sixth  and  sev- 
enth grades.  It  was  not  only  more  difficult  to  secure 
cooperation  from  the  homes  but,  with  children  of 
their  age,  home  cooperation  was  less  effective,  as 
many  of  them  were  quite  beyond  parental  control. 
Moreover,  it  was  far  more  difficult  to  enlist  their  own 
cooperation.  This  was  especially  true  of  the  seventh 
grade  in  which  there  were  a  number  of  over-age 
boys,  who  had  lost  all  interest  in  school  activities, 
and  were  merely  marking  time,  and  waiting  to  take 
out  their  working  papers.  These  big  fellows  consti- 
tuted an  unruly  element,  and  to  a  certain  extent  w^ere 
leaders  because  of  their  years  and  daring.  Obvi- 
ously, their  level  of  intelligence  was  inferior.  Their 
cooperation  w^as  never  successfully  enlisted.  The 
nutrition  program  w^as  regarded  by  them  as  ''baby- 
ish," and  the  difficulties  in  discipline  experienced  in 
the  lunch  room  and  during  the  rest  period  emanated 
for  the  most  part  from  them.  The  sixth  grade  group 
had  also  its  quota  of  retarded  boys,  but  they  were 
proportionately  fewer  and  the  greater  differences 
in  physiological  age  existing  between  them  and  the 
younger  members  of  their  class  rendered  their  influ- 
ence less  disturbing.    The  comparative  results  ob- 


56  HEALTH  EDUCATION 

tained  in  these  two  groups,  120%  for  the  sixth  grade 
group  and  111%  for  the  seventh  grade,  seem  to  de- 
pend in  the  main  on  this  factor  of  their  personnel. 

The  failure  of  the  fifth  grade  to  make  gains  is 
easily  explained  in  view  of  the  circumstances  sur- 
rounding the  mid-day  dinner,  and  the  additional  fact 
that  no  attempt  to  enlist  their  cooperation  by  a  pro- 
gram of  instruction  was  made.  It  will  be  noted 
(Table  I)  that  this  grade  showed  the  largest  num- 
ber of  underweights  and  as  individuals  they  may 
have  represented  more  serious  problems  of  malnu- 
trition or  of  physical  defect  than  did  the  other 
classes.*  In  addition,  the  age  period  of  the  average 
fifth  grade  boy  offers  a  possible  contributing  cause. 
(See  p.  23.)  The  only  fact  established  by  their  place 
in  the  experiment  is  the  failure  of  the  school  lunch 
to  compete  with  a  more  comprehensive  program. 

Like  the  fifth  grade,  the  open-air  group  of  this 
first  year  cannot  be  considered  comparable  to  the 
others.  It  undoubtedly  included  incipient  cases  of 
disease  and  its  members  were  probably  candidates 
for  a  far  more  controlled  regime  than  could  be  sup- 
plied through  the  school  procedure.  As  it  seemed 
impractical  to  send  the  members  of  this  group  to  the 
eye  clinic,  class  instruction  was  given  them  in 
their  own  room.  As  the  rest  of  the  class  did  not 
share  in  this,  there  was  always  a  consciousness 
among  them  that  they  were  on  a  different  basis  from 
the  others,  and  a  resulting  lack  of  cooperation  was 
probably  a  factor  in  their  poor  record. 

Although  the  program  of  school  feeding  plays  no 

*  No  physical  examinations  were  made  or  social  histories  taken  for 
this  group.  After  the  initial  height  and  weight  taking  they  were 
merely  given  the  mid-day  dinner. 


THE  INITIAL  PROGRAM 


57 


part  in  our  interpretation  of  relative  gains  made  by 
the  several  groups,  there  can  be  little  doubt  that  the 
actual  gains  made  by  the  Terman,  sixth,  seventh, 
and  first  grade  classes  were  due  in  considerable 
part  to  the  mid-morning  luncheons.  It  is  also 
probable  that  the  mid-day  dinner  afforded  some  re- 
sults for  the  Terman  group,  because  of  probable 
better  and  more  intelligent  cooperation  on  their  part 
in  this,  as  in  other  features  of  the  program. 

PHYSICAL  DEFECTS 

Naso-pJiaryngeal  Obstructions. — A  comparison  of 
the  49  children  who  were  recommended  for  tonsil 
and  adenoid  operation  and  failed  to  secure  treat- 
ment, with  the  32  children  who  were  free  from  such 
defects  appears  in  Table  V.  As  the  groups  were  not 
of  equal  size  the  percentages  best  indicate  the  rela- 
tive results. 

TABLE  V 

Comparative    Gains    op    Children    without    Naso-Pahryngeal 
Obstructions  and  Those  Recommended  for  Operation 


With 
Obstructions 

Without 
Obstructions 

No. 

Per  Cent 

No. 

Per  Cent 

Lost  weight 

4 
IS 

24 

3 

8.2 
36.7 

49 

6.1 

1 
9 

12 

10 

3.1 

Gained  less  than  normal 

28.1 

Gained  more  than  normal, 
100% 

1  to 

37 

Gained  more  than  normal, 
100% 

over 

31.3 

49 

100 

32 

100 

From  this  table  it  is  evident  that  55.1%  of  the 
children  from  whom  these  defects  were  not  removed 


58 


HEALTH  EDUCATION 


made  gains  in  excess  of  normal  while  68.8%  of  the 
children  without  such  defects  gained  in  excess  of 
normal.  The  relative  amount  of  gain  must  be  noted, 
however,  and  the  record  of  gains  showing  over  100% 
in  excess  of  normal  is  only  6.17o  for  children  having 
defects  as  against  31.3%  for  those  without  defects. 
A  study  of  the  gains  made  by  19  *  of  the  cases 
operated  for  a  period  of  five  weeks  before  and 
five  weeks  after  the  operation  is  given  in  Table  VI. 
In  practically  every  case  the  child  lost  weight  at  the 
time  of  the  operation  and  recovered  it  in  about  a 
week.  The  five-week  periods  are  therefore  separated 
in  each  case  by  a  few  intervening  days  in  which  this 
recovery  was  taking  place. 


TABLE  VI 

Per  Cent  Gain  of  19  Children  for  Period  of  Five  Weeks  before 
AND  Five  Weeks  after  Tonsil  and  Adenoid  Operation 


No. 

Before 

After 

No. 

Before 

After 

1 

2.4 

1.4 

11 

-1.3 

2.5 

2 

3.6 

8.2 

12 

1.1 

3.3 

3 

1.7 

1.0 

13 

0.6 

1.9 

4 

0  5 

5.6 

14 

-0.9 

3.4 

5 

-0.3 

1.5 

15 

3.3 

4.6 

6 

-1.3 

3.4 

16 

5.8 

-1.3 

7 

0.6 

2.5 

17 

0.9 

4.0 

8 

-2.8 

5.8 

18 

-0,3 

4.7 

9 

2.8 

3.9 

19 

-1.7 

1.5 

10 

0.9 

6.4 

Carious  Teeth. — Of  the  entire  group  88  were  ex- 
amined for  dental  caries  and  63  were  found  to  have 

*  One  child  of  the  20  operated  is  not  included  owing  to  an  attack 
of  influenza  following  his  operation. 


THE  INITIAL  PROGRAM 


59 


from  1  to  12  carious  teeth.  An  attempt  was  made 
to  correlate  this  defect  with  the  degree  of  under- 
weight found,  but  this  was  unsuccessful.  The  re- 
sults of  the  study  are  given  in  Table  VII. 

TABLE  VII 

Comparison  of  Dental  Caries  and  Average  Percentage 
Underweight 


No.  of  Carious  Teeth 

No 
Record 

0 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

No.  of  children 

Average  per  cent  un- 
derweight   

17 
10 

25 
10 

21 
9 

12 

S 

9 
13 

8 
9 

3 
10 

3 
10 

2 
16 

2 
10 

1 
13 

1 
9 

0 
0 

1 

13 

Summary 

At  the  end  of  the  first  school  term  no  spectacular 
gains  had  been  made  by  the  children  enrolled  in  our 
nutrition  classes.  On  the  contrary,  progress  had 
been  slow  and  discouraging.  The  results  achieved 
in  *' percentage  of  normal  gain"  fell  far  short  of 
our  attempted  goal,  and  of  the  entire  number  en- 
rolled (105)  only  two  had  '^ graduated"  by  reaching 
the  standard  weight  for  their  height  and  age. 

In  the  light  of  subsequent  experience  these  results 
appear  less  disappointing  and  we  can  appreciate  to- 
day that  the  standards  used  in  making  our  evalua- 
tions were  too  high,  as  they  were  based  on  an  '' ex- 
pected gain"  in  the  determination  of  which  no  allow- 
ance for  the  factor  of  seasonal  variation  had  been 
made.  Not  until  two  years  later  did  our  staff  become 
aware  of  the  importance  of  this  seasonal  factor  and 
of  its  effect  on  previously  accepted  standards.  But 
the  complexity  of  our  problem,  and  of  the  underlying 


60  HEALTH  EDUCATION 

causes  and  contributing  factors  of  malnutrition  had 
been  pretty  well  revealed  to  us  by  June  of  the  first 
year. 

The  outstanding  facts  of  the  first  five  months' 
experience  may  be  briefly  stated  as  follows:  The 
wide  variations  in  response  shown  by  the  individual 
records  had  emphasized  the  importance  of  the  child's 
physical  status  and  home  conditions  in  determining 
results.  At  the  same  time  the  relative  gains  of  the 
several  classes  had  brought  into  relief  the  depend- 
ence of  success  on  the  child's  own  cooperation  and 
the  necessity  of  better  techniques  for  enlisting  it. 
In  comparison  with  these  essential  factors  the  dif- 
ferences in  the  various  programs  arranged  were 
shown  to  be  negligible.  Better  cooperation  from  the 
home,  better  progress  in  the  correction  of  defects, 
more  careful  physical  examination  and  diagnosis 
and  a  better  class  procedure  were  felt  to  be  neces- 
sary lines  of  development,  if  we  were  to  cope  suc- 
cessfully with  the  problems  involved. 

Certain  limitations,  too,  were  apparent  in  the 
chart  forms  and  other  records  used  during  the  first 
term.  These  had  been  copied  from  those  in  use  at 
the  Massachusetts  General  Hospital  and  were  better 
adapted  to  gathering  the  type  of  material  needed  for 
purposes  of  clinical  diagnosis  than  for  collecting 
data  for  statistical  treatment.*  As  a  result  of  our 
experience  in  the  first  term's  work  we  developed  an 

*  For  similar  difficulties  experienced  with  physical  examination 
records  see  Dewey,  Child  and  Ruml,  op.  cit.,  p.  160,  and  Heron,  The 
Influence  of  Defective  Phi/sique  and  Unfavorable  Home  Environment 
on  the  Intelligence  of  Children,  Galton  Laboratory  Memoirs  VIII. 
1910.  ' 


THE  INITIAL  PROGRAM  61 

individual  record  blank  resembling  in  some  re- 
spects that  used  by  the  visiting  teachers  of  the  city. 
The  weight  chart  was  somewhat  modified  as  well 
to  suit  our  particular  needs.* 

*  See  Appendix  B  and  C. 


CHAPTEE  IV 

DEVELOPMENT  OF  PROCEDURE— GRAMMAR 
GRADES— SEPTEMBER,  1918— JUNE,  1919 

Basis  of  Reorganization 

In  organizing  the  classes  for  the  second  year,  an 
attempt  was  made  to  develop  our  program  in  direc- 
tions calculated  to  secure  better  control  of  the  envi- 
ronment and  added  opportunities  for  enlisting  the 
children's  cooperation,  since  the  experience  of  the 
first  year  had  emphasized  the  importance  of  these 
factors  in  securing  weight  increase.  As  no  convinc- 
ing results  in  favor  of  the  mid-day  dinner  had  been 
afforded,  it  was  decided  to  give  up  this  feature  of 
the  experiment  and  to  work  more  intensively  along 
other  lines.  The  work  of  the  New  York  School 
Lunch  Committee  had  been  discontinued  at  the  end 
of  the  previous  term  and  their  cooperation  was  no 
longer  available.  Without  their  aid  an  attempt  to 
secure  a  hearty  meal  at  school  for  any  of  our  classes 
presented  many  difficulties  beyond  the  increased  ex- 
penditure of  money  and  service  involved.  Dr. 
Emerson's  belief,  that  such  a  meal  though  advan- 
tageous is  not  necessary  to  the  success  of  the  nutri- 
tion class  program,  was  an  influential  factor  in  reach- 
ing the  decision  to  discontinue  it,  especially  since  his 
opinion  appeared  to  be  confirmed  by  our  data. 

62 


o 


DEVELOPMENT  OF  PROCEDURE     63 

Viewed  in  the  light  of  our  subsequent  experience 
and  with  the  statistics  for  three  consecutive  years 
available,  the  decision  to  discard  entirely  so  im- 
portant a  feature  of  the  program  at  so  early  a 
stage  of  the  experiment  now  appears  question- 
able. More  serious,  however,  was  the  basis  on 
which  the  new  classes  in  the  fall  of  1918  were 
organized.  Not  one  of  these  will  be  found  strictly 
comparable  to  any  of  the  groups  organized  in 
the  previous  year.  Thus  the  advantages  to  be 
gained  by  continuing  to  set  up  really  comparable 
groups  within  a  single  experiment,  and  at  the  same 
time  incorporating  new  features  of  treatment,  were 
largely  lost  at  P.  S.  64,  and  the  statistics  gathered 
in  the  three  successive  years  hardly  lend  themselves 
for  purposes  of  comparison.  Two  types  of  influence 
were  responsible  for  the  changes  which  so  seriously 
affected  our  program  of  research :  on  the  one  hand 
the  advisability  of  conforming  to  the  practical  situ- 
ation and  modifying  plans  in  accordance  with  ad- 
ministrative and  financial  considerations,  on  the 
other  the  temptation  to  sacrifice  the  statistical  re- 
quirements for  possible  benefits  to  the  individual 
child.  The  organization  of  the  classes  in  the  fall  of 
1918  exhibits  the  latter  influence  very  clearly.  Any 
such  undertaking  as  ours  must  inevitably  experience 
the  pressure  of  influences  in  these  two  directions,  and 
workers  should  realize  that  so  far  as  they  find  it 
inadvisable  to  carry  out  a  consistent  program  on  the 
basis  of  verifying  and  expanding  previous  experi- 
ence and  accumulating  comparable  data,  the  possi- 
bilities for  much-needed  research  are  endangered. 


64  HEALTH  EDUCATION 

GROUP  SELECTION 

From  the  viewpoint  of  benefit  to  the  individual 
our  first  need  in  the  fall  of  1918  appeared  to  be  pro- 
vision for  those  children  who  had  been  in  our  classes 
the  year  before  and  were  still  underw^eight.  With 
a  view  to  securing  the  best  environmental  conditions 
available  for  them  Dr.  Louis  Marks,  the  Principal 
of  P.  S.  64,  arranged  for  two  open-air  classes,  one 
for  sixth  and  seventh  grade  children,  the  other  for 
those  of  the  fourth  and  fifth  grades.  In  these  were 
enrolled  members  of  the  nutrition  groups  from  the 
fifth,  sixth  and  seventh  grade  and  open-air  classes 
of  the  previous  year.  To  these  were  added  a  number 
of  boys  from  the  same  grades,  selected  at  the  open- 
ing of  school  as  conspicuously  underweight.  There 
were  also  a  few  pre-tubercular  cases  for  whom  the 
school  had  to  provide  open-air  facilities.  Thus  the 
two  open-air  classes  presented  the  special  problems 
of  a  higher  average  underweight,  and  a  more  or  less 
chronic  condition  of  malnutrition,  as  shown  by  fail- 
ure to  respond  to  previous  treatment. 

A  third  class  w^as  recruited  entirely  from  fifth 
grade  boys  whose  average  condition  as  to  under- 
weight was  not  serious.  This  group  was  selected 
with  a  view  to  developing  an  educational  procedure 
under  usual  class  conditions,  and  determining  how 
far  the  borderline  and  low  percentile  cases  would 
respond  to  such  a  procedure.  It  was  hoped  results 
w^ould  show  that  by  making  special  provision  for  the 
more  serious  cases,  a  school  could  secure  satisfactory 
results  for  the  majority  of  its  underweight  children, 
through  further  development  and  adaptation  of  the 
nutrition  class  program  to  typical  school  conditions. 


DEVELOPMENT  OF  PROCEDURE     65 

The  choice  of  fifth  grade  children  for  this  ex- 
perimental group  was  determined  partly  by  the  un- 
satisfactory showing  of  the  fifth  grade  in  the  pre- 
vious year,  partly  by  considerations  of  administra- 
tive convenience. 

ADMINISTRATIVE  ADJUSTMENT 

Dr.  Marks'  decision  to  form  entire  classes  of  un- 
derweight children  was  a  distinct  gain  to  our  pro- 
cedure, as  it  made  possible  the  development  of  an 
esprit  de  corps  among  the  class  members  that  was 
impossible  as  long  as  they  were  distributed  amon^ 
the  different  classes  of  their  grade,  and  assembled 
only  for  the  weekly  sessions  in  the  eye  clinic  room. 
Class  instruction  for  the  open-air  groups  was  of 
necessity  given  in  their  own  class-rooms,  and  at  mid- 
year the  same  plan  was  adopted  for  the  fifth  grade 
boys.  Thus  the  eye  clinic  came  to  be  used  only 
for  measurements,  examinations  and  individual  in- 
terviews. The  conduct  of  the  weekly  class  sessions 
was  given  to  the  two  nutrition  workers  who  now  as- 
sumed this  responsibility  in  addition  to  their  pre- 
vious duties.* 

Physical  Care 

This  change  made  for  efficiency  in  the  program  of 
physical  care,  as  the  physician's  time  could  now  be 
devoted  entirely  to  the  physical  examinations  and 
diagnosis,  and  to  individual  interviews,  when  it 
seemed  necessary  to  true  up  the  findings  of  the  nutri- 
tion worker  or  give  special  advice.    The  added  au- 

*  The  subsequent  developments  in  teaching  methods,  and  techniques 
for  better  enlistment  of  cooperation  from  the  children  and  from  the 
homes,  were  made  under  the  direction  of  Miss  Harriet  A.  Forbea. 


66  HEALTH  EDUCATION 

thority  of  any  recommendation  from  the  doctor  was 
always  evident  and  could  be  relied  on  for  securing 
additional  emphasis  when  necessary. 

Results  obtained  in  the  correction  of  defects 
showed  an  appreciable  gain  over  those  of  the  first 
year.*  Tonsil  and  adenoid  cases  were  treated  at  the 
Metropolitan  Hospital.  The  treatment  of  dental 
caries  was  continued  conscientiously  but  progressed 
slowly  owing  to  the  inadequate  provision  of  clinics 
for  the  purpose.  Had  it  not  been  for  the  interest 
and  kindness  of  a  skillful  and  busy  dentist  in  prac- 
tice, Dr.  H.  A.  Koonz,  who  treated  many  of  our 
children  without  a  fee,  it  would  have  been  impossible 
to  secure  dental  treatment  for  them. 

Cooperation  of  the  Home 

In  spite  of  the  failure  of  parents  to  attend  the 
class  meetings  of  the  previous  year,  we  continued  to 
urge  them  to  be  present  in  the  belief  that  our  work 
would  gradually  enlist  interest  and  better  coopera- 
tion, as  the  individual  families  and  the  community 
at  large  became  more  fully  aware  of  its  significance. 
Our  attempts  to  secure  their  attendance  continued 
all  through  the  second  year  of  the  experiment,  but 
as  time  wore  on  and  our  realization  of  the  need  of 
home  cooperation  increased,  we  were  led  to  increase 
the  number  of  home  visits  considerably.  The  better 
to  enlist  the  mother's  interest  a  miniature  copy  of 
the  child's  weight  chart  was  taken  by  the  nutrition 
worker  on  these  visits  and  carefully  explained 
to  her. 

Frequently    during    such    a    visit    the    nutrition 

*  See  p.  87  (statistical  data). 


DEVELOPMENT  OF  PROCEDURE     67 

worker  was  able  to  persuade  the  mother  to  prepare 
cereal  and  to  serve  smaller  portions  when  trying  to 
establish  the  habit  of  eating  more  nourishing  food; 
or  she  was  encouraged  to  make  greater  effort  to  pre- 
vent late  hours,  and  in  various  other  ways  to  give  her 
aid  to  the  experiment.  Almost  invariably  we  found 
her  keenly  interested  in  her  boy's  health,  and  fre- 
quently the  cooperation  given  was  invaluable.  A  spe- 
cial problem  of  the  nutrition  class  program  is  the 
difficulty  of  assessing  the  accuracy  of  the  children's 
statements  concerning  their  home  regime.  Facts 
gathered  during  the  home  visits  served  as  a  check 
on  the  child's  reports  as  to  his  habits  and  were  used 
to  corroborate  them  or  the  reverse.  Where  testi- 
mony was  conflicting,  that  bearing  the  best  indica- 
tion of  good  faith  and  accuracy  was  taken. 

Fifth  Grade  Class 

ENVIRONMENT 

Except  in  the  extreme  winter  weather  the  windows 
of  the  fifth  grade  room  were  kept  open.  The  boys 
wore  their  outdoor  sweaters  and  coats,  and  enjoyed 
the  fresh  air.  Rest  periods  were  arranged  during 
the  morning  session,  the  children  remaining  seated 
with  arms  and  heads  on  the  desks  before  them.  In- 
struction in  relaxation  was  given  in  connection  with 
these  attempts  at  conserving  energy,  and  a  certain 
success  was  achieved,  though  with  boys  of  this  age 
the  problem  was  difficult,  and  five  minutes  of  real 
relaxation  was  almost  as  much  as  could  be  secured 
in  a  fifteen  minute  period.  The  children  were  urged 
to  bring  mid-morning  lunches  from  home  and  a  reg- 
ular time  was  arranged  for  eating  them.    The  at- 


68  HEALTH  EDUCATION 

tempt  to  secure  home  cooperation  in  the  provision  of 
these  hmches  was  never  more  than  partially  success- 
ful. Failure  to  supply  them  was  frequent,  and  those 
brought  averaged  much  below  the  caloric  value  pre- 
scribed (250-300  calories).  Often  a  small  apple  or 
an  unappetizing  roll  would  be  their  only  constituent. 

MOTIVATION 

Every  effort  was  made  to  enlist  a  spirit  of  coop- 
eration among  the  children  sufficient  to  ensure  the 
carrying  out  of  the  health  program  at  home.    As  has 
been  stated,  the  change  in  class  organization  was  a 
gain  in  this  respect,  and  a  further  advantage  resulted 
from  the  decision  reached  at  mid-year,  to  hold  the 
class  instruction  sessions  in  the  regular  class-room 
instead  of  the  eye  clinic  room.    The  familiarity  of 
the  surroundings,  better  acquaintance  between  the 
members  of  the  class  and  the  presence  of  the  class 
teacher,  the  resulting  informality  and  closer  identi- 
fication of  the  procedure  with  usual  school  interests 
and  attitudes,  all  contributed  to  establishing  a  class 
spirit.    The  idea  of  competition  between  individual 
members  of  the  class  was  dropped,  and  children  were 
urged  to  exceed  their  own  previous  record  instead. 
A  significant  change,  too,  was  made  in  the  chart 
where  the  normal  weight  line  was  supplemented  by 
the  ''line  of  expected  gain"  for  the  individual,  the 
two  together  forming  a  zone  within  which  progress 
could  be  considered  achievement.*     By  this  device 
some  discouragement  on  the  part  of  those  who  could 
not  approximate  the  standard  of  normal  weight  for 
height  was  avoided.    At  the  same  time  the  use  of 

*  See  Appendix  C. 


DEVELOPMENT  OF  PROCEDURE     69 

the  colored  markers  in  connection  with  the  charts 
became  more  evidently  one  of  records  rather  than 
rewards.  The  familiarity  of  the  nutrition  worker 
with  the  weekly  records,  and  the  facts  of  home  en- 
vironment and  individual  history,  made  possible 
more  careful  interpretation  of  the  charts,  at  the 
same  time  that  discussion  of  them  was  made  briefer 
and  more  impersonal. 

These  changes  in  class-room  technique  made  for 
increased  effectiveness  in  securing  the  cooperation  of 
the  children.  An  additional  stimulus  was  furnished 
by  giving  the  boys  some  realization  of  the  meaning 
of  the  class  as  an  experiment.  They  were  interested 
to  feel  themselves  part  of  a  serious  investigation  of 
the  means  by  which  the  percentage  of  underweight 
in  their  school  could  be  reduced.  That  they  really 
grasped  something  of  their  own  place  in  the  experi- 
ment and  of  its  social  significance,  was  evidenced 
by  the  increased  care  with  which  they  made  their 
weekly  reports  as  this  conception  became  clearer. 
The  question  may  well  be  raised  how  far  such  a 
special  appeal  can  be  regarded  as  legitimate  in  an 
educational  experiment.  Certainly  any  successful 
results  obtained  are  less  convincing  for  a  general 
program  because  of  its  use.  Whatever  response  may 
be  secured  from  an  individual  group  by  keeping 
before  them  the  fact  that  they  are  pioneers,  and  that 
the  future  of  others  depends  on  their  record  of  suc- 
cess or  failure,  the  necessity  of  securing  no  less 
active  cooperation  from  succeeding  classes  must  be 
kept  in  mind. 

The  work  was  started  late  in  November.  By  mid- 
January  an  attitude  of  habitual  participation  and 


70  HEALTH  EDUCATION 

ease  of  manner  during  discussions  was  manifest, 
and  there  was  no  sign  of  the  self-consciousness  noted 
the  previous  year  nor  of  the  clinical  atmosphere. 

SUBJECT  MATTER 

If  the  teaching  of  the  nutrition  workers  was  less 
authoritative  than  that  of  the  physicians,  it  was  also 
less  didactic  and  more  stimulating  to  the  child's  own 
thinking.  An  aim  kept  constantly  in  view  was  to 
lead  discussion  away  from  the  individual  records 
and  consideration  of  the  charts,  to  topics  emphasiz- 
ing health  and  constructive  suggestions  for  living 
habits,  not  only  for  the  class  but  for  their  families 
and  the  community.  This  resulted  in  the  develop- 
ment of  a  considerable  program  of  subject  matter 
which  proved  full  of  interest  for  the  children.  The 
content  involved  is  shown  in  the  f  ollomng  summary, 
derived  from  the  class  discussions  for  a  period  of 
28  weeks.  Subjects  were  reviewed  repeatedly  with 
no  apparent  loss  of  interest,  and  a  new  fact  was  re- 
ceived with  absorbed  attention  by  the  majority  of* 
the  class. 

Correct  weighing  and  care  of  scales. 

The  nature  of  an  experiment — its  social  value — the  scientific  atti- 
tude of  mind. 

What  constitutes  good  nutrition. 
The  calorie — a  unit  of  heat. 
The  uses  of  food: 

As  fuel — for  heating  the  body. 

As  fuel — for  maintaining  the  internal  activities  (respiration,  cir- 
culation, etc.). 

As  fuel — to  produce  energy  for  all  kinds  of  work  and  play. 

As  fuel — for  reserve  energy,  storage  for  emergency  uses. 

For  repair. 
The  significance  of  measured  feeding. 


DEVELOPMENT  OF  PROCEDURE  71 

The  value  of  certain  foods — milk,  cereals,  vegetables,  fruits,  meat, 
eggs. 

The  nature  of  habit  formation. 

Food  habits. 

Other  factors  in  promoting  good  nutrition — fresh  air,  rest,  exercise. 

Prevention  and  treatment  of  physical  defects. 

Care  of  the  teeth. 

Effect  of  tonsil  and  adenoid  obstructions. 

Eye  strain. 

It  took  several  weeks  for  the  children  to  get  a 
working  knowledge  of  caloric  values,  and  to  under- 
stand not  only  the  term  but  the  significance  of  the 
body's  fuel  needs.  The  dramatic  storj-  of  the  college 
boys  whose  willing  immolation  in  the  calorimeter 
made  them  heroes  in  the  minds  of  the  class,  was  used 
as  the  starting  point  of  this  interest.  The  idea  of 
measured  feeding  followed  naturally,  with  the  con- 
ception of  food  as  fuel  and  a  source  of  energy  for  the 
human  machine.  The  need  to  regulate  the  supply  as 
the  engineer  does  for  his  monster  of  iron  and  steel 
was  also  evident.  Then  followed  special  uses  of  dif- 
ferent foods  and  the  relative  values  of  those  found 
in  their  own  dietaries  or  available  for  them.  Wax 
models  showing  100  calorie  portions  of  suitable 
breakfast  dishes  were  secured,  to  assist  in  the  inter- 
pretation of  caloric  values  in  terms  of  daily  experi- 
ence, and  to  demonstrate  a  few  menus  for  the  ideal 
breakfast.  On  one  occasion  several  children  from 
the  open-air  classes  were  taken  for  a  trip  to  the 
Post-Graduate  Hospital,  where  a  very  complete  ex- 
hibit of  this  kind  is  to  be  seen,  with  a  view  to 
helping  them  estimate  more  accurately  the  caloric 
value  of  the  food  portions  served  them  at  home. 
Samples   of  real  food  were   occasionally  used  in 


72  HEALTH  EDUCATION 

conjunction   with   the   wax   models    for   this   type 
of  illustration.     Mention  was  made   of   acquiring 
proper  food  habits,  and  at  one  lesson  a  psychologist 
was  present,  and  explained  habit  formation  to  the 
class.    This  talk  was  frequently  referred  to  by  the 
children  afterwards.     Incidentally,  some  important 
conceptions  of  the  value  and  interest  of  work  done 
in  the  scientific  spirit,  and  of  the  exactness  required 
in  carrying  out  the  details  of  scientific  work  were 
gained.    In  the  study  of  pure  milk,  for  example,  each 
child  could  get  a  picture  of  the  interrelationship  of 
the  processes  involved  in  getting  milk  from  farm  to 
child  consumer,  and  could  feel  the  disastrous  effect 
of  failure  on  the  part  of  any  individual  to  perform 
his  part  conscientiously.    Their  interest  in  facts  and 
changes  recorded  on  charts  other  than  their  own  was 
indicative  of  this  budding  scientific  spirit,  and  as  the 
year  progressed  the  class  discussions  increasingly 
reflected  it.     The  boys  would  gather   around   the 
charts  eagerly  talking  about  the  gains  and  losses  in 
a  surprisingly  impersonal  tone.     The  assertion  of 
a  boy  on  one  occasion,  "When  I  drink  milk  I  don't 
gain ;  when  I  drink  coffee  I  do, "  was  met  by  a  chorus 
of  exclamations  and  demands  for  an  explanation. 
During  a  discussion  of  the  plan  to  give  a  demon- 
stration in  the  auditorium,  one  boy  volunteered  the 
suggestion  that  all  charts  should  be  shown  whether 
good  or  bad.    This  was  talked  over  pro  and  con  as 
to  its  usefulness,  and  no  one  suggested  that  his  chart 
should  be  omitted. 

This  auditorium  program  took  place  late  in  the 
year  and  was  arranged  by  the  class  at  the  sugges- 
tion of  the  principal.    It  was  sufficiently  successful 


DEVELOPMENT  OF  PROCEDURE     73 

to  bring  a  request  from  the  teachers  that  a  regular 
auditorium  period  be  taken  over  by  the  nutrition 
classes.  The  wax  food  models  were  shown  and  ex- 
plained by  the  boys,  as  well  as  several  of  the  weight 
charts,  two  from  the  fifth  grade,  and  two  from  each 
of  the  open-air  classes.  The  boys  who  had  secured 
treatment  for  physical  defects  then  marched  on  the 
stage  in  two  groups,  and  a  spokesman  explained 
what  they  had  done  to  become  better  fit. 

The  few  stories  introduced  in  the  class  work  were 
true  ones.  Interest  in  Roosevelt  and  his  determina- 
tion to  overcome  his  weakness  of  body  was  keen,  and 
Horace  Fletcher,  w^ith  his  ideas  about  eating,  w^as 
well  received.  On  several  occasions  a  visitor  re- 
corded portions  of  the  class  discussion  to  which  she 
listened,  and  the  following  quotations  from  her  note 
book  are  of  interest  in  connection  with  the  problem 
of  home  environment : ' '  My  baby  leaves  out  his  milk, 
but  now  I  make  him  drink  it. "  '  ^  My  sister  goes  to 
bed  earlier. "  " My  big  brother  didn't  believe  in  eat- 
ing slowly,  but  he  tried  it  and  he  gained."  "Now 
I  get  my  brother  and  sister  to  eat  the  same  things.'* 

In  the  month  of  May  the  boys  were  asked  to  write 
compositions  on  the  value  of  the  Nutrition  Class  and 
urged  to  tell  exactly  what  they  thought  of  it,  ''for 
and  against. ' '  About  one-half  of  the  33  papers  were 
against  the  class,  largely  because  of  the  ''bother  of 
tonsil  operations."  Rest  was  also  referred  to  many 
times  as  perhaps  the  greatest  "bother"  of  all,  re- 
quiring much  self-control  and  resolution  to  put 
through.  The  compositions  in  general  are  note- 
worthy for  their  sincerity  and  freedom  of  speech,  in 
decided  contrast  to  what  is  usual  in  the  class-room. 


74  HEALTH  EDUCATION 

Even  where  disapproval  is  expressed,  as  in  the  fol- 
lowing excerpt,  we  can  realize  that  the  writer  had 
gained  something  from  the  experience:  '*I  like  to 
go  to  bed  late  and  I  like  to  eat  fast.  I  donH  like 
the  idea  of  the  calories.  The  nutrition  class  is  good 
for  those  who  like  it."  A  more  submissive  spirit 
tells  us:  *'I  used  to  take  a  roll  and  run  out  in  the 
street  and  play.  Now  I  learned  to  eat  a  roll  and  sit 
down  by  a  table  and  have  more  a  joyable  time."  The 
following  quotation  shows  the  common  attitude  of 
the  boys  when  they  were  in  the  class-room :  ''I  am  in 
the  nutrition  class  and  I  think  I  am  here  long  enough 
to  know  whether  it  has  helped  me  or  not.  When  I 
was  not  in  the  nutrition  class  I  did  not  know  that  I 
ought  not  to  drink  tea  or  coffee.  I  know  enough  to 
go  to  sleep  early  and  try  to  take  rest  periods  or  lunch 
periods  and  know  nearly  everything  that  Avill  make 
me  gain." 

ESTIMATE  OF  METHODS 

It  will  be  recalled  that  the  program  developed  for 
this  group  was  undertaken  to  determine  how  far 
results  could  be  secured  from  the  nutrition  class 
under  typical  school  conditions.  For  this  reason  the 
type  of  class  instruction  used  presents  several  fea- 
tures for  special  consideration,  and  well  illustrates 
the  possibilities  and  limitations  of  health  teaching 
under  the  conditions  imposed.  It  will  be  evident 
that  the  socialized  recitations  with  their  appeal  to 
group  psychology,  effectively  secured  the  interest  of 
the  children,  whose  enjoyment  of  the  weekly  discus- 
sions, and  increased  facility  of  expression  and  ease 
of  manner   as   the   year   progressed,   were   noted 


DEVELOPMENT  OF  PROCEDURE     73 

by  all  who  observed  them.  Partly  because  of 
these  conditions,  partly  because  of  the  natural 
interest  nearly  all  children  feel  for  the  subject 
matter  covered,  it  was  possible  to  present  it 
always  in  its  scientific  aspect  and  from  the 
''work  level '^  approach.  The  class  instruction 
used  will  be  recognized  as  the  best  of  its  kind 
and,  as  an  informational  procedure,  was  highly  suc- 
cessful. The  subsequent  record  of  the  children 
affords  evidence  that  it  was  fairly  successful  also, 
in  establishing  a  creative  attitude  on  their  part 
toward  the  problem  of  health.  As  a  weight-getting 
and  habit-forming  program,  however,  it  undoubt- 
edly left  much  to  be  desired,  and  in  this  respect  its 
limitations  were  the  limitations  incident  to  the  usual 
public  school  environment,  when  equipment  and  fa- 
cilities for  radical  readjustment  of  existing  condi- 
tions are  not  provided.  We  may  well  ask  ourselves 
what  might  have  been  the  results  in  weight  increase, 
had  mid-session  luncheons  or  a  mid-day  dinner  and 
rest  facilities,  similar  to  those  provided  for  groups 
in  the  previous  year,  been  arranged  for  these  chil- 
dren, whose  cooperation  and  interest  had  been  so 
effectively  appealed  to,  and  the  causal  factors  of 
whose  underweight  were,  for  the  most  part,  of  a  less 
serious  nature  than  in  the  case  of  other  groups  con- 
sidered. 

Open-Air  Classes 

ENVIRONMENT 

The  open-air  classes  throughout  the  school  system 
are  designed  to  provide  special  conditions  to  meet  the 
needs  of  children  handicapped  because  of  tubercular 


76  HEALTH  EDUCATION 

diathesis,  anaemia  or  serious  malnutrition.  Children 
suffering  from  various  other  maladies  of  a  nature 
which  does  not  exclude  them  from  school,  easily  drift 
into  these  classes,  so  that  in  the  minds  of  many  chil- 
dren they  have  become  identified  with  the  idea  of 
sickness  and  ill-health  and  to  a  certain  degree  carry 
a  resulting  stigma. 

As  existing  in  P.  S.  64  they  presented  the  follow- 
ing points  of  distinction  from  the  rest  of  the  school: 
a  sunny  room  with  windows  adjusted  in  order  to 
swing  and  be  open  the  year  around,  army  cots  with 
blankets  or  sleeping  bags  for  daily  rest  periods, 
movable  desks  and  chairs,  mid-morning  luncheon, 
a  bonus  for  the  teacher  in  order  to  secure  a  woman 
with  special  social  and  technical  qualifications.  With 
such  a  modification  of  the  school  environment,  and 
with  health  rather  than  school  progress  the  goal 
before  the  class,  there  is  an  inevitable  slowing  down 
of  the  usual  speed  in  class-room  procedure,  with  a 
consequent  gain  in  informality,  all  of  which  is  obvi- 
ously of  benefit  to  the  child,  and  in  close  accord  mth 
the  ideal  program  for  the  nutrition  class.  In  the 
two  rooms  placed  at  our  disposal,  therefore,  we  had 
only  to  make  use  of  features  already  existing,  the 
daily  rest  period  with  the  children  lying  flat  on  the 
back  for  three-quarters  of  an  hour,  sleeping  when 
possible,  but  always  remaining  quiet  in  a  recumbent 
position,  and  the  mid-morning  lunch  which  was 
served  in  the  class-room.  In  the  open-air  rooms  the 
need  of  extra  nourishment,  especially  in  winter 
weather,  is  always  recognized,  and  lunches  for  them 
have  been  regularly  supplied  at  P.  S.  64  through 
outside  subscription. 


DEVELOPMENT  OF  PROCEDURE     77 

During  the  coldest  weather  oatmeal  or  farina  with 
milk  was  served  and  taken  generally  with  relish, 
although  appetites  for  the  most  part  needed  tempt- 
ing in  these  particular  groups,  and  it  was  found 
necessary  to  vary  the  luncheon  as  circumstances  per- 
mitted. Hot  cocoa  was  sometimes  substituted  for 
the  cereal  and  milk.  The  cooking  was  done  by  one 
of  the  teachers  on  a  small  gas  stove  in  the  teachers' 
lunch  room;  and  a  fireless  cooker  was  available, 
thanks  to  the  teacher  of  one  class,  who  had  been  suf- 
ficiently energetic  to  have  it  made  by  one  of  the 
boys  in  the  school  shop.  In  warm  weather  a  good 
grade  of  bottled  milk  was  served,  also  bread  and 
jelly  sandwiches,  or  bread  and  jam. 

With  the  facilities  at  her  disposal  the  serving  of 
even  these  simple  lunches  was  something  of  an 
achievement  for  the  class  teacher  Any  educational 
possibilities  incident  to  the  selection,  purchase,  and 
preparation  of  them  could  not  be  made  available  for 
the  children  under  the  circumstances.  The  actual 
serving  and  eating,  however,  presented  opportunity 
for  a  certain  training  in  food  habits,  and  for  discus- 
sion of  caloric  intake  and  food  values,  while  the 
group  example  doubtless  played  its  part  in  helping 
individuals  to  cultivate  a  taste  for  milk  and  cereals. 

INSTEUCTION 

The  open-air  groups  offered  less  opportunity  for 
the  development  of  class  discussions  and  subject 
matter  content,  because  of  the  shorter  lesson  periods 
arranged  for  them.  A  special  feature  used  by  the 
nutrition  worker  in  these  classes  was  a  small  indi- 
vidual chart  which  the  child  himself  prepared  at  his 


78  HEALTH  EDUCATION 

desk  and  took  home  with  him,  being  thus  enabled 
to  discuss  his  record  with  his  family  from  week  to 
week. 

A  unique  use  of  stories  was  made  by  this  worker, 
who  finding  the  boys  in  the  lower  class  familiar  with 
and  fond  of  some  of  the  wonder  book  tales,  retold 
The  Golden  Touch  and  the  story  of  Penelope,  the 
boys  maldng  their  own  applications,  in  the  case  of 
Midas  sufficiently  evident.  Penelope,  who  unravelled 
at  night  the  work  of  every  day,  was  compared  td 
those  children  who  undid  the  benefits  of  fresh  air 
during  their  school  day  by  sleeping  with  closed  win- 
dows at  night. 

Statistical  Data  and  Interpretations 

GROUP   SELECTION 

Open-Air  Classes. — Of  the  48  children  enrolled  in 
the  open-air  classes,  29  had  been  carried  over  from 
the  nutrition  classes  of  the  previous  year  for  failure 
to  respond  to  treatment.  Of  this  number  12  presented 
special  problems  and,  although  they  were  seriously 
underweight,  no  satisfactory  diagnosis  of  the  causes 
for  their  condition  was  made  in  the  two  years  they 
remained  under  our  care,  nor  did. they  make  gains 
in  spite  of  their  own  sincere  efforts  at  cooperation, 
the  enlistment  of  their  parents'  interest,  and  the  best 
efforts  of  our  staff.  Sixteen  of  the  class,  one-third 
of  the  total  enrollment,  were  pre-tubercular  cases 
and,  while  a  number  of  these  were  not  seriously 
underweight,  they  contributed  their  quota  to  the 
difficulties  of  securing  gains.  The  remaining  mem- 
bers had  been  enrolled  because  they  were  conspicu- 
ously underweight.  Table  VIII  shows  the  distribution 


DEVELOPMENT  OF  PROCEDURE 


79 


of  percentages  underweight  for  these  groups  at  the 
initial  weighing  in  September,  and  again  at  the  final 
weighing  in  June.  It  will  be  seen  that  just  half  of 
them  were  seriously  underweight,  above  11%  for 
height,  and  only  13  of  the  48  were  low  percentile 
cases.  The  results  at  the  final  weighing  show  a  slight 
approximation  to  normal. 


Open-air  Classes: 


TABLE  VIII 

Distribution  of  Percentages   Underweight 
AT  Different  Dates 


First  Weighing 

Final  Weighing 

-  3 

-   5 

5 

-  5 

-  7 

2 

-  7 

-  9 

13 

7 

-  9 

-11 

11 

11 

-11 

-13 

6 

« 

-13 

-15 

10 

7 

-15 

-17 

3 

5 

-17 

-19 

2 

2 

-19 

-21 

3 

1 

48 

48 

Fifth  Grade  Classes. — ^Five  classes  of  fifth  grade 
boys,  223  pupils  in  all,  were  weighed  and  measured 
and  of  the  total  number  74,  or  23.19%  were  found  7% 
or  more  underweight.  Of  this  number  13  were 
placed  in  the  lower  open-air  group,  and  39  were 
enrolled  in  the  fifth  grade  nutrition  class,  measure- 
ments being  taken  with  indoor  clothing  and  without 
shoes.  Owing  to  various  delays,  the  Liberty  Loan 
drive  in  which  the  older  children  were  active,  and 
the  epidemic  of  Spanish  influenza,  which  disorgan- 


80 


HEALTH  EDUCATION 


ized  the  schools  for  a  period,  this  class  did  not  begin 
its  sessions  until  nearly  seven  weeks  after  the  initial 
weighing,  when  it  was  found  that  22  of  the  number 
were  no  longer  1%  underweight.  Table  IX  gives 
the  distribution  of  their  percentages  underweight  at 
the  initial  weighing  in  the  latter  part  of  September, 
and  again  at  the  first  class  meeting  in  November 
when,  as  may  be  seen,  12  individuals  were  found  to 
be  between  5  and  7%  underweight  and  10  more  were 
from  1  to  5%  underweight. 

TABLE  IX 

Fifth  Grade  Class:    Distribution  of  Percentages  Underweight 
AT  Different  Dates 


Percentages 

First  Weighing 

First  Class 

Final  Weighing 

3           1 

1 

1     -   1 

-   1     -  3 

1 

1 

-  3     -  5 

9 

-  5     -  7 

12 

2 

-  7     -  9 

19 

8 

8 

-  9     -11 

11 

4 

5 

-11     -13 

4 

1 

6 

-13     -15 

4 

2 

7 

-15     -17 

1 

6 

-17     -19 

1 

1 

5 

-19     -21 

2 

Total.... 

39 

39 

43 

These  unexpected  graduates  afforded  the  spec- 
tacular element  in  the  year's  record.  It  will  be  re- 
called that  of  the  total  enrollment  (105)  in  the  pre- 
vious Spring,  only  two  were  ''graduated"  in  the 
course  of  19  weeks  of  serious  effort  to  provide  a 


DEVELOPMENT  OF  PROCEDURE     81 

corrective  program.  Now  by  contrast,  we  had  22 
ready  to  "graduate"  from  a  group  of  only  39  after 
a  term  of  seven  weeks  and  before  any  program  of 
care  or  instruction  had  been  begun.  Not  until  the 
publication,  eighteen  months  later,  of  Dr.  Porter's* 
statistics  on  seasonal  variation  was  a  satisfactory 
interpretation  offered.  For  although  the  fall  has 
long  been  recognized  as  the  probable  season  of  maxi- 
mal weight  increase,  no  previous  study  has  shown 
how  large  a  percentage  of  the  total  annual  incre- 
ment is  involved  in  such  variation.  In  the  light  of 
Dr.  Porter's  investigation  our  spectacular  feature 
appears  easily  accounted  for.  Heavier  under-cloth- 
ing at  the  second  weighing  in  November  probably 
proved  a  contributing  factor,  but  it  is  not  sufficient 
of  itself  to  provide  an  explanation. 

Since  it  was  impractical  to  reorganize  the  class, 
all  school  arrangements  for  the  term  having  been 
made,  and  the  usual  school  program  being  more  or 
less  seriously  delayed  already  by  the  unusual  con- 
ditions attending  the  influenza  epidemic,  these  22 
children  remained  in  the  class.  The  final  approxi- 
mation to  normal  weight  and  its  distribution  is 
shown  in  the  last  column  of  Table  IX.  Here  the 
effect  of  Dr.  Porter's  season  of  minimal  weight  in- 
crease seems  as  apparent  as  that  of  the  season  of 
maximal  increase  in  the  results  for  the  period  of  the 
first  seven  weeks.  Less  spectacular  perhaps,  it 
proved  far  more  disconcerting  to  the  workers  con- 
ducting the  experiment.  Comparing  the  first  weigh- 
ing with  the  final  weighing,  the  cases  are  found  to 

*  Porter,  Wm.  T.,  Seasonal  Variation  in  the  Growth  of  Boston 
School  Children,  American  Journal  of  Physiology,  May,   1920. 


82 


HEALTH  EDUCATION 


be  more  uniformly  distributed  but  no  decided  ap- 
proach to  normal  is  shown. 

Control  Group. — 

A  Control  Group  of  35  children  who  were  approx- 
imately of  average  weight  for  their  height  was 
selected  at  the  time  of  the  first  weighing,  with  a  view 
to  studying  the  variability  exhibited  by  normal  chil- 
dren, for  the  light  it  might  throw  on  problems  of 


CoNTEOL    Group: 


TABLE  X 
Distribution    op    Weight    Percentages    at 

Different  Dates 


Percentages 

First  Weighing 

Second  Weighing 

Third  Weighing 

12 

1 

11 

10 

9 

1 

8 

1 

7 

1 

6 

4 

6 

2 

1 

4 

1 

1 

3 

4 

3 

2 

2 

3 

3 

4 

1 

4 

4 

0 

6 

5 

6 

-1 

4 

3 

3 

-2 

7 

1 

3 

-3 

7 

3 

-4 

1 

-6 

1 

1 

-« 

3 

-7 

1 

-8 

1 

-9 

1 

8 

5 

35 

27 

DEVELOPMENT  OF  PROCEDURE     83 

underweight,  especially  in  regard  to  the  discrimina- 
tion of  temporary  and  chronic  cases.  A  study  of 
mental  ability  in  underweight  children  which  formed 
part  of  our  program  demanded  similar  data  derived 
from  well-nourished  children  for  purposes  of  com- 
parison. Table  X  shows  the  results  of  the  measure- 
ments for  this  group  taken  in  the  fall,  in  February 
at  the  beginning  of  the  second  school  term,  and  in 
the  first  week  of  May.  Unfortunately,  at  this  third 
weighing  8  of  the  children  could  not  be  secured, 
so  our  results  are  for  27  instead  of  35.  At  the  first 
weighing  all  the  children  were  within  3%  of  aver- 
age weight  for  their  height,  at  the  second  weighing 
they  varied  from  97c  under  to  12%  overweight,  and 
at  the  final  weighing  the  27  children  measured  ranged 
from  8%  underweight  to  5%  overweight.  A  marked 
variability  is  thus  apparent,  first  in  the  general 
direction  of  gain,  only  two  falling  below  the  original 
minimum  (—3%)  for  the  entire  group,  later  a  very 
general  trend  in  the  direction  of  loss  is  apparent. 
It  will  be  seen  that  the  history  of  the  Control  Group 
exhibits  the  same  general  features  as  to  variability 
shown  by  the  Nutrition  Groups  and  further  confirms 
Dr.  Porter's  findings. 

EESIILTS  IN  WEIGHT  INCREASE 

The  comparative  results  achieved  by  the  open-air 
and  indoor  groups  are  shown  by  Chart  A,  where  the 
shaded  column  represents  the  fifth  grade  classes  and 
the  plain  column  the  open-air  classes.  The  base  line 
indicates  the  periods  for  which  results  were  cal- 
culated: A  the  first  seven  weeks,  B  the  first  twelve 
weeks,  C  after  nineteen  weeks,  and  D  the  final  re- 


84 


HEALTH  EDUCATION 


380 

' 

.a«o 

93Q 

300 
480 

1 

160 

1 

140 

1 

i 

130 

IDA  .......... 

i 

i 

m 

////// 

1 

m 

i 
i 

P 

i 
y//A 

P 

1 

13 
B 


19 
C 


30 
D 


CHART  A 
Comparative  Gains,  Fifth  Grade  and  Open-air  Classes 


DEVELOPMENT  OF  PROCEDURE  85 

suit,  after  twenty-seven  weeks  for  the  fifth  grade 
and  thirty-two  weeks  for  the  open-air  classes.  The 
height  of  the  columns  shows  the  average  per  cent 
of  gain.  It  will  be  seen  that  the  open-air  classes 
in  the  first  twelve  weeks  increased  274:%  of  the  nor- 
mal gain,  whereas  in  nineteen  weeks  their  increase 
was  125%,  and  in  the  entire  period  111%.  The  first 
and  final  difference  is  not  so  great  for  the  children 
of  the  fifth  grade  classes.  In  the  first  seven  weeks 
between  the  original  weighing  and  the  first  meeting 
of  the  class,  the  average  gain  in  relation  to  normal 
was  208%.  In  the  first  twelve  weeks  it  had  decreased 
to  156%  and  was  approximately  the  same  at  nine- 
teen weeks,  but  for  the  entire  period  it  was  only 
106%. 

The  percentage  of  gain  for  the  fifth  grade  class 
from  week  to  week  is  shown  in  Chart  B,  the  base 
line  indicating  weeks,  and  the  figures  at  the  left 
percentage  of  gain.  The  chief  interest  of  this  record 
is  the  fluctuation  shown  in  parade  week  and  again 
in  promotion  week.  The  loss  incidental  to  the  ex- 
citement and  strain  of  examinations  is  approxi- 
mately 0.6%.  The  gain  for  the  entire  period  of 
twenty-seven  weeks  is  approximately  9%. 

Our  attempts  to  find  correlation  between  the  per- 
centage of  gain  and  such  features  of  our  procedure 
as  caloric  intake,  the  number  of  rest  periods  ob- 
served, the  number  of  lunches  taken,  were  unsuccess- 
ful. With  data  gathered  from  a  larger  number  of 
individuals  it  might  have  been  possible  to  establish 
clear  cut  correlations  but  even  so  the  evidence  as  to 
the  value  of  any  one  of  these  taken  by  itself  would 
hardly  be  convincing — such  testimony  would  indi- 


86 


HEALTH  EDUCATION 


10 


to 


so 


40 


3.0 


XHAS 


TTIO  MOTION 


10 


15- 


20 


2? 


CHART  B 

Percentages  of  Gain  from  Week  to  Week — Fifth  Grade  Class 

Note. —  The  fluctuation  sJwvni  in  the  eighteenth  week  coincides  with  the  date  of  tht 
parade  by  which  the  return  of  the  city  troops  was  celebrated. 


DEVELOPMENT  OF  PROCEDURE  87 

cate  rather  their  value  as  contributing  factors  to  the 
results  obtained  by  the  general  regime. 

PHYSICAL  DEFECTS 

Naso-pharyngeal  Obstructions. — Thirty  children, 
or  35%  of  the  87  enrolled,  were  recommended  for  re- 
moval of  naso-pharyngeal  obstructions,  and  of  these 
23,  or  76.6%  of  the  number  recommended,  had  opera- 
tions arranged  for  them  in  the  course  of  the  year, 
although  the  conditions  incident  to  the  influenza 
epidemic  delayed  the  treatment  in  all  but  two  cases 
until  early  Spring.  Any  resulting  benefits  therefore 
cannot  have  played  an  appreciable  part  in  the  class 
record  of  gains  for  the  year. 

Of  the  30  children  recommended  for  operation,  13 
were  from  the  open-air  group  and  represented  27% 
of  their  total  enrollment.  This  relatively  low  per- 
centage of  naso-pharyngeal  defects  among  the  group 
of  high  percentile,  chronic  underweights  was  partly 
accounted  for  by  the  enrollment  among  them  of  chil- 
dren operated  on  the  year  before.  The  indoor  groups 
also  presented  a  better  condition  in  respect  to  these 
defects  than  had  been  the  case  the  previous  year, 
only  17  children,  or  44%  of  their  enrollment  being 
recommended  for  operation. 

Only  10  of  the  23  cases  operated  secured  treat- 
ment at  a  date  early  enough  to  permit  a  five  weeks* 
period  of  observation  after  the  necessary  interval 
for  weight  recovery.  Chart  C  shows  the  curve  of 
gain  for  these  10  cases  for  five  weeks  previous  to 
the  operation,  as  well  as  for  the  five  weeks  following 
their  recovery  of  weight.  The  intervening  period, 
4.6  weeks,  during  which  they  were  recovering  from 


88 


HEALTH  EDUCATION 


♦3. 


♦1 


-1 


4.6  ffaeks 
Raoovary 

from 
Operation 


S  Waok» 

Ton«lf 
Ope  r  a.  t  ion 


CHART  C 

Progress  op  10  Children  before   and   after    Operation   fob 

Naso-pharyngeal  Obstructions 


DEVELOPMENT  OF  PROCEDURE 


89 


the  effects  of  the  operation,  is  indicated  by  the  dotted 
line.  The  percentage  of  gain  is  —.4%  for  the  period 
before  and  2.1%  for  the  period  after  the  defects 
were  removed. 


MENTAL  ABILITY 

The  results  of  the  comparative  study  of  mental 
ability  in  underweight  and  normal  children  under- 
taken this  year  *  were  briefly  as  follows :  In  tests 
of  motor  control  there  was  no  marked  difference 
shown  between  the  Nutrition  and  the  Control  Group 
either  in  the  separate  series  of  tests  as  given  at  the 
beginning  and  at  the  end  of  the  Nutrition  Class 
period,  or  in  improvement  as  shown  by  the  differ- 
ences between  the  first  and  second  results.  When  the 
combined  scores  for  the  two  series  are  considered  we 
get  a  slight  difference  in  favor  of  the  Control  Group 
in  the  two  tests  measuring  physical  endurance — 
Eapidity  of  Movement  (Tapping)  and  Strength  of 
Grip  (Dynamometer).  In  the  Steadiness  Test  the 
Nutrition  Group  has  a  little  advantage. 


Tapping 

Dynamometer 

Steadiness 

R.  H. 

L.  H. 

R.  H. 

L.  H. 

R.  H. 

L.  H. 

Nutrition 

298.5 
306.7 

269.4 
265.6 

32.0 
32.6 

29.6 
30.4 

4.8 
4.45 

3.55 

Control 

3.4 

In  the  following  tests  of  mental  processes  the 
averages  of  the  combined  scores  for  both  trials  show 

*  For  a  more  complete  report  of  this  study  see  Mahmtrition  and 
Health  Education,  by  David  Mitchell  and  Harriet  A.  Forbes,  Peda- 
gogical  Seminary,  March,   1920. 


90 


HEALTH  EDUCATION 


superiority  of  the  Nutrition  Group  in  five  of  the 

seven  tests. 


Trabue  Completion 

Memory  Span 

Association  Reaction  Time 

Directions 

Cancellation 

Knox  Cubes 

Dearborn  Reconstruction . . 


Nutrition 

Control 

10.05 

8.85 

6.4 

6.05 

2.6 

3.1 

3.5 

3.3 

6.95 

6.95 

6.9 

7.3 

151. 

148.5 

The  Trabue  Completion  Scales  which  give  a  high 
correlation  with  standardized  intelligence  scales 
show  similar  distributions  of  scores.  Superiority  of 
the  undernourished  children  is  indicated.  These 
average  scores  differ  so  little  and  the  sampling  is 
so  small,  one  is  not  justified  in  asserting  that  sig- 
nificant differences  are  found  between  the  two 
groups.  It  can  be  claimed  that  these  undernour- 
ished children  are  equal  in  mental  ability  if  not 
superior  to  the  well-nourished  children. 


INTERPRETATIONS 

Evaluation  of  procedures  in  this  second  experi- 
ment is  more  difficult  than  in  the  case  of  the  preced- 
ing one,  where  groups  were  established  on  a  fairly 
equal  basis  and  with  definite  variables  as  points  of 
comparison.  It  will  be  apparent,  however,  that  the 
advantage  in  gain  shown  by  the  open-air  classes  is 
of  significance  in  view  of  their  personnel.  The 
variety  of  retarding  factors  they  exhibited  must  be 
borne  in  mind  when  we  contrast  the  year's  record 


DEVELOPMENT  OF  PROCEDURE     91 

made  by  tliem  with  that  of  the  fifth  grade.  When 
allowance  is  made  for  the  physical  disparity  between 
the  two  groups,  and  especially  when  we  recall  that 
of  48  open-air  boys,  12,  or  25%  of  the  number,  failed 
to  respond  at  all  owing  to  unknown  factors  pre- 
sumably of  disease  or  organic  deficiency,  the  facts 
of  their  relative  response  become  emphatic.  It 
would  appear  that  the  special  factors  determining 
this  response  must  have  particular  significance  for 
the  efficient  health  program,  if  on  analysis  they  can 
be  isolated. 

It  will  be  recalled  that  special  emphasis  was  laid 
on  fresh  air  in  the  fifth  grade  class-room  and  that 
their  windows  were  kept  open  except  in  extreme 
weather.  Thus  it  is  evident  that  the  results  for  the 
first  twelve  weeks  shown  at  B  (Chart  A)  were  for 
gains  made  in  a  season  during  all,  or  nearly  all  of 
which  the  windows  were  kept  open.  In  the  interval 
between  B  and  C,  however,  we  may  assume  that  the 
fifth  grade  was  conducted  as  a  closed-window  class, 
with  frequent  changes  of  air  by  direct  ventilation 
and  temperature  lower  than  that  of  the  average 
class-room.  During  the  greater  part  of  the  interval 
between  C  and  B  this  arrangement  must  have  ob- 
tained as  the  final  determinations  were  made  for  the 
fifth  grade  early  in  May.  Comparison  of  results  at 
B,  C  and  B,  therefore,  gives  no  evidence  that  open 
windows  were  a  determining  factor,  as  the  superior 
gains  of  the  open-air  groups  at  B  were  made  when 
the  fifth  grade  was  conducted  as  an  open-window 
room,  the  superior  gains  of  the  fifth  grade  at  C  and 
its  inferior  gains  at  B  seem  to  argue  the  dependence 


92  HEALTH  EDUCATION 

of  the  results  obtained  on  factors  other  than  open 
air. 

The  food  experiences  arranged  for  the  open-air 
groups  were  much  better  calculated  to  influence  gains 
than  those  given  to  the  fifth  grade.  The  hot  mid- 
morning  luncheons  of  cereal  and  milk  or  cocoa  were 
admirably  calculated  to  supplement  the  home  diet- 
ary and  educate  a  taste  for  the  milk  and  cereals  so 
lacking  in  the  Jewish  bill  of  fare.  The  meagre  cold 
lunches  brought  from  home  by  the  fifth  grade  boys 
added  little  to  the  actual  caloric  intake  and  nothing 
to  the  broadening  of  dietary  habits.  But  there  is 
probably  an  added  reason  for  the  greater  effective- 
ness of  the  lunches  served  to  the  open-air  groups  in 
the  undoubted  stimulation  to  metabolism  and  conse- 
quent better  assimilation  resulting  from  out-of-door 
atmosphere.  We  may  go  further  in  making  our  com- 
parison here  and  infer  that  the  inadequate  lunches 
brought  by  the  fifth  grade  boys  were  less  adequate 
during  the  period  of  open  windows,  when  metabo- 
lism and  assimilation  were  thus  stimulated,  and  more 
adequate  in  the  period  preceding  the  determinations 
made  at  C,  after  a  season  of  closed  windows.* 

Comparison  of  the  rest  periods  for  both  groups 
of  children  is  obviously  greatly  in  favor  of  the  open- 
air  classes.  Indeed  it  is  hardly  an  exaggeration  to 
say  that  the  rest  periods  in  the  fifth  grade  provided 
a  dramatic  rather  than  a  real  experience  of  rest, 
although  a  certain  conception  of  relaxation  and  how 
to  secure  it  was  doubtless  gained  by  the  children. 

*  See  Hill,  Leonard,  special  report,  English  Medical  Eesearch  Com- 
mittee, The  Science  of  Ventilation  and  Open  Air  Treatment,  Part  I, 
1919.  A  series  of  observations  on  heat  production  of  man  in-  and 
out-of-doors  is  discussed. 


DEVELOPMENT  OF   PROCEDURE  93 

Again,  we  cannot  isolate  the  factor  of  rest  from  that 
of  temperature,  but  must  consider  the  combined 
effects  of  both  in  estimating  the  open-air  environ- 
ment. That  the  physiological  effects  of  rest  and 
sleep  in  cold  air  with  warm  body  coverings  are  of 
particular  tonic  value,  is  a  fact  well  recognized  in 
therapeutics  although  as  yet  not  fully  explained  by 
science.  That  blood  pressure  is  thereby  increased, 
heart  action  strengthened,  and  nerves  steadied,  has 
been  demonstrated  in  some  cases  of  acute  illness, 
notably  pneumonia.* 

How  far  data  on  the  blood  pressure  and  heart 
action  of  well  children  under  similar  conditions  may 
serve  to  reinforce  the  open-air  program  has  yet  to 
be  ascertained.  It  seems  apparent,  however,  that 
the  significance  of  the  open-air  class  does  not  lie  in 
any  one  of  its  special  provisions  but  rather  in  the 
physiological  effect  resulting  from  the  interaction 
of  all  three. 

The  factor  of  sunshine  like  that  of  ''fresh"  air 
evidently  played  no  determining  part  in  securing 
results,  as  the  open-air  class-rooms  both  had  a  south- 
ern exposure  and  were  flooded  with  sunshine,  while 
the  fifth  grade  was  in  a  north  room  until  mid-year 
or  during  the  two  periods  A  to  B  and  B  to  C,  when 
their  gains  were  successively  less  and  greater  than 
those  of  the  open-air  boys. 

Cooperation  on  the  part  of  the  children  and  of 
the  homes  was  fairly  comparable  in  both  groups, 
although  interest  was  probably  established  some- 
what earlier  in  the  open-air  classes,  because  of  their 

*  See  Discussion  of  Papers  on  Fresh  Air  Schools  by  Dr.  John  W. 
Brannan — Transactions  Fourth  Int.  Congress  on  School  Hygiene, 
1913,  Vol.  II,  p.  171. 


94  HEALTH  EDUCATION 

special  significance  in  the  minds  of  both  parents  and 
children,  and  because  of  the  number  of  children  in 
them  carried  over  from  the  experiment  of  the  year 
before.  The  longer  period  of  educational  influence 
to  which  these  had  been  subjected  may  well  have  re- 
sulted in  better  cooperation  at  the  outset,  and 
greater  gains  during  the  period  of  maximal  weight 
increase  may  also  have  resulted  from  a  previous  im- 
provement in  their  home  regime.  The  removal  of 
tonsil  and  adenoid  defects  during  the  preceding  year 
probably  proved  a  contributing  factor  too,  but  we 
must  assume  that  these  possible  advantages  could 
hardly  offset  the  failure  on  the  part  of  25%  of  their 
total  enrollment  to  gain  at  all.  Rather  it  seems  rea- 
sonable to  accept  the  difference  between  the  gain  of 
274%  and  156%'  shown  at  B,  as  the  probable  increase 
resulting  from  the  combined  environmental  factors 
of  lunches,  rest,  fresh  air  and  lighter  school  pro- 
gram at  the  season  specially  favorable  to  increase, 
over  and  above  the  gains  to  be  expected  from  the 
seasonal  period  itself  and  the  program  of  instruc- 
tion. 

The  results  shown  at  C  suggest  that  the  sea- 
sonal period  of  minimal  growth  may  retard  gains 
for  the  high  percentile  underweight  rather  more 
than  for  the  low  percentile  and  normal  child,  and 
that  the  advantageous  factors  of  environment  for 
the  open-air  classes  were  insufficient  to  compensate 
for  the  better  resistance  to  winter  conditions  offered 
by  the  fifth  grade,  who  were  now  probably  beginning 
to  show  the  results  of  educational  influences  and  im- 
proved home  regime,  in  addition  to  their  better 
physical  endowment. 


DEVELOPMENT  OF  PROCEDURE     95 

The  determinations  at  D  demand  a  special  word 
of  explanation.  As  all  but  two  of  the  children  oper- 
ated for  tonsil  and  adenoid  obstructions  during  the 
school  year  were  treated  in  the  period  between  G 
and  D,  results  for  weight  increase  in  both  groups 
are  correspondingly  lowered.  In  addition  the  gen- 
eral discouragement  felt  by  children  and  parents  as 
the  year  drew  to  a  close  and  it  became  obvious  that 
the  promised  results  of  the  nutrition  program  were 
not  being  realized,  resulted  at  last  in  lessened 
efforts  and  frequent  lapses  in  regime.  Thus  the 
lessened  results  at  D  are  really  not  representative 
and  a  final  estimate  of  the  year 's  work  should  not  be 
based  on  them.* 

So  far  as  the  results  shown  by  Chart  A  lend  them- 
selves to  analysis,  we  may  conclude  their  testimony 
is  to  the  importance  of  environmental  factors  for 
securing  early  results,  and  to  the  better  ability  of 
the  low  percentile  and  normal  child  to  gain,  even 
under  less  favorable  circumstances  of  environment, 
during  the  period  of  minimal  weight  increase. 

Summary 

In  June,  1919,  after  a  full  school  year  of  intensive 
work  our  results  in  terms  of  weight  increase  ap- 
peared so  slight  as  to  be  almost  negligible.  Appre- 
ciable improvement  in  our  procedure  had  not 
brought  corresponding  gains  to  the  children  in  our 
classes.  In  spite  of  more  adequate  physical  care, 
increased  control  of  the  environment  and  better 
teaching  technique,  we  seemed  as  far  from  our  goal 
as  we  had  been  in  the  previous  June.    The  facts  of 

*  See  later  showing  of  fifth  grade  boys,  pp.  146  aud  149. 


96  HEALTH  EDUCATION 

Dr.  Porter's  investigation,  it  will  be  remembered, 
were  not  available  to  our  workers  until  nearly  twelve 
months  later,  and  we  were  therefore  without  the  key- 
by  which  our  apparent  failure  could  be  properly  in- 
terpreted. The  initial  gains  of  the  fall  were  for- 
gotten, in  view  of  the  inexplicable  failure  to  gain 
through  the  second  term  of  school,  and  as  the  year 
progressed  and  the  discouragement  of  the  season 
of  minimal  increase  was  felt  by  all,  the  educational 
fallacy  of  holding  out  to  the  children  promises  of 
results  that  were  not  to  be  realized,  however  well 
informed  or  willing  their  cooperation,  was  keenly 
appreciated  by  the  members  of  our  staff. 

While  the  conviction  remained  with  those  who  had 
observed  the  fifth  grade  class,  that  such  a  subject 
matter  program  as  had  been  developed  for  them  was 
a  valuable  addition  to  the  procedure,  the  statistical 
data  for  the  year  brought  into  relief  the  better  show- 
ing of  the  open-air  classes,  and  emphasized  the  im- 
portance of  more  adequate  provision  in  the  school 
environment  for  the  actual  practice  of  health-mak- 
ing activities  by  contrast  with  class  discussion  of 
them.  As  a  natural  corollary  the  importance  of 
parental  cooperation  to  provide  increased  opportu- 
nities for  a  health-making  regime  at  home  received 
corresponding  emphasis. 

But  the  development  of  a  subsequent  program 
planned  to  secure  further  enlistment  of  home  co- 
operation, and  to  permit  greater  emphasis  on  ac- 
tivities and  environmental  conditions  in  the  school, 
hardly  promised  a  solution  of  our  major  problems, 
even  though  the  general  efficiency  of  our  procedure 
should  be  increased  thereby.     Our  experience  with 


DEVELOPMENT  OF  PROCEDURE  97 

the  ** graduates"  of  the  early  fall  who  later  fell  back 
into  the  ranks  of  underweight,  and  the  fluctuations 
shown  by  the  control  group  had  raised  serious  ques- 
tions as  to  the  standards  we  were  using.  The  failure 
to  secure  response  from,  or  even  to  diagnose  the 
twelve  cases  transferred  from  the  groups  of  the 
previous  year  to  the  open-air  classes,  indicated  the 
insufficiency  of  our  knowledge  in  regard  to  certain 
types  of  malnutrition.  The  need  for  a  program  of 
study  involving  more  detailed  observations  of  height 
and  weight  increment,  and  more  careful  physical  ex- 
amination and  diagnosis  had  become  apparent,  if  we 
were  to  make  real  progress  in  solving  the  problems 
raised  by  our  experience.  Moreover,  the  negative 
results  from  our  study  of  mental  ability  called  for 
further  investigation  in  this  field,  where  we  had  ob- 
tained findings  so  much  at  variance  with  precon- 
ceived opinion. 


CHAPTER  V 

DEVELOPMENT  OF  PROCEDURE— PRIMARY 
GRADES— SEPTEMBER,  1919— JUNE,  1920 

Basis  of  Reorganization 

In  planning  our  work  for  the  next  school  year  it 
was  decided  to  experiment  with  first  grade  children 
and  to  concentrate  our  efforts  on  developing  a  pro- 
cedure suited  to  their  needs.  It  mil  be  recalled  that 
our  initial  program  in  1918  included  a  first  grade 
class  and  that  they  had  shown  surprising  gains  in 
comparison  with  the  other  classes,  in  spite  of  the 
fact  that  little  attempt  had  been  made  to  adapt  our 
procedure  to  the  special  demands  of  their  age  period. 
In  the  belief  of  our  workers  the  great  solicitude  felt 
by  the  parents  for  children  in  their  first  school  year, 
and  the  type  of  home  cooperation  afforded  in  conse- 
quence, offered  an  explanation  of  our  relative  suc- 
cess with  the  first  grade  class;  and  it  was  believed 
that  by  development  of  a  program  further  enlisting 
home  cooperation  for  such  a  group,  proportionally 
better  results  could  be  secured.  At  the  same  time, 
the  first  grade  was  felt  to  be  the  logical  beginning 
for  any  program  of  instruction  depending  in  the 
main  on  activities  rather  than  subject  matter.  If 
school  tradition  still  confuses  the  teacher  who  is 
trying  to  think  in  terms  of  activity  rather  than  in- 
formation, the  same  is  equally  true  of  the  nutrition 


DEVELOPMENT  OF  PROCEDURE     99 

worker.  But  in  classes  where  the  possibility  of  in- 
formational content  is  reduced  to  its  lowest  terms 
by  the  limitations  of  the  age  period,  it  would  seem 
possible  to  carry  out  such  a  change  in  class  proce- 
dure to  the  best  advantage.  The  immaturity  of  the 
six-year-old  makes  equally  impossible  the  reduction 
of  the  educational  program  to  informational  mate- 
rial, and  the  shifting  of  responsibility  for  gains  from 
the  adults  in  control  of  the  environment  to  the  child 
himself. 

In  addition  to  our  program  for  first  grade  children, 
the  boys  of  the  previous  year's  fifth  grade  class  were 
weighed  and  measured  monthly,  with  a  view  to 
studying  their  record  and  determining,  if  possible, 
any  long  term  results  that  might  have  been  afforded 
by  the  nutrition  class  procedure.  Careful  measure- 
ments of  control  groups  for  both  classes,  the  first 
grade  and  the  previous  year's  fifth  grade  were 
planned,  more  thorough  physical  examinations  were 
arranged,  and  a  more  extensive  program  of  mental 
measurements  was  included. 

GEOUP  SELECTION 

Forty  first  grade  children  ranging  from  8  to  20% 
underweight  were  enrolled  in  the  nutrition  class 
organized  in  September,  1919.  The  group  was  seg- 
regated and  an  experienced  class-room  teacher  who 
was  interested  to  cooperate  with  the  nutrition  staff 
was  assigned  them  for  the  school  year.  Owing  to 
the  early  transfer  of  2  boys  the  class  was  reduced 
to  38  members.  Of  this  number  8  were  replaced 
later  in  the  school  term  because  of  transfer  to  other 
schools  or  failure  of  promotion  at  mid-year. 


100  HEALTH  EDUCATION 

In  February,  14  children  from  7  to  22%  under- 
weight for  height,  were  found  among  the  mid-year 
entrants  to  the  first  grade.*  These  formed  a  second 
nutrition  group.  Associated  with  them  were  5  boys 
not  promoted  with  the  September  group. 

ScJiool  Procedure. 

INDrVTDUAL  INSTRUCTION 

Weights  were  taken  weekly  in  the  eye  clinic  room 
and  the  results  written  on  a  report  slip  for  each 
child  to  take  home.  These  slips  created  much  inter- 
est at  home  and  among  the  children.  Every  other 
week  individual  instruction  was  given  in  connection 
with  the  weight  taking.  The  child's  chart  was  used 
and  his  progress  marked  by  a  red  crayon  dot  placed 
on  it  in  his  presence,  the  black  line  being  filled  in  by 
the  nutrition  worker  afterwards.  Neither  the  "nor- 
mal weight  line"  nor  the  line  of  "expected  gain" 
appeared  on  the  charts,!  and  the  boys  were  not  con- 
scious of  being  underweight,  they  were  simply  en- 
couraged to  form  health  achieving  habits,  to  try 
to  make  gains  and  if  possible  to  beat  their  own  pre- 
vious records.  In  the  beginning  the  charts  were 
meaningless  to  them,  as  thoy  could  not  read  their 
own  names  nor  follow  the  figures;  but  they  soon 
grasped  the  significance  of  the  "up  and  down" 
weight  line. 

CLASS    INSTRUCTION 

On  alternate  weeks  class  instruction  was  given  by 
the  nutrition  worker  for  a  period  of  fifteen  minutes 

*  See  "  Growth  in  Weight  and  Height, ' '  p.  119, 
t  See  Appendix  C. 


DEVELOPMENT   OF  PROCEDURE  101 

and  included  a  story.  The  chart  showing  the  best 
progress  for  the  fortnight  was  displayed  on  the  wall 
and  attention  called  to  it  as  a  recognition  of  achieve- 
ment. Except  for  these  best  records  the  children 
saw  only  their  o^\^l  charts,  and  discussed  their  indi- 
vidual progress  only  with  the  nutrition  worker,  or 
at  home. 

A  special  subject  for  class  discussion  was  selected 
for  each  month,  and  the  short  stories  told  at  the  end 
of  the  session  were  chosen  to  emphasize  the  subject 
under  consideration.  Each  contained  an  obvious 
and  simply  expressed  lesson  on  health  habits,  and  a 
feature  was  made  of  repetitive  and  rhythmical  para- 
graphs in  which  the  class  could  join  and  thereby 
secure  the  active  sense  of  participation  so  important 
for  holding  interest  at  this  age  period.  '^What  the 
Milk  Told  Me,"  ''The  Pig  Brother,"  ''How  Bobby's 
■Food  Turned  into  More  Bobby,"  "The  Rain-drops," 
"Little  Potato,"  were  the  stories  successfully  used 
for  these  children.*  Their  recital  was  followed  by 
informal  discussion  and  by  the  spontaneous  dram- 
atizations characteristic  of  modem  story  telling  for 
the  primary  grades.  The  particular  content  covered 
by  the  series  involves  the  importance  of  cleanliness, 
of  water  drinking,  of  milk  and  vegetables  in  the  diet, 
and  a  conception  of  the  processes  of  digestion,  re- 
duced to  very  simple  terms.  The  class  dramatiza- 
tion of  "The  Story  the  Milk  Told  Me"  was  given 
by  12  of  the  boys  at  the  Grand  Central  Palace  during 
the  week  of  the  New  York  Milk  and  Child  Health 
Campaign.    The  breakfast  food  models  were  shown 

*"What  the  Milk  Told  to  Me,"  by  Gertrude  Noyes,  from  the 
collection  In  the  Child's  World,  by  Poulsson;  "The  Pig  Brother,"  by 
Laura  E.  Eichardsj   the  other  three  stories  are  unpublished. 


102  HEALTH  EDUCATION 

in  connection  with  class  discussion,  and  were  supple- 
mented by  specimens  of  fresh  green  vegetables 
brought  by  the  nutrition  worker. 

ENVIRONMENT 

Lunches. — The  attempt  to  have  mid-morning 
lunches  provided  by  the  homes  was  definitely  aban- 
doned and  an  8-ounce  glass  of  good  milk  substituted 
for  the  uncertainties  of  home  catering.  This  was 
served  at  the  Nathan  Straus  Milk  Station  in  Tomp- 
kins Square  at  10:15  every  day,  when  the  children 
went  over  to  the  square  for  their  playground  period. 
Later,  when  severe  weather  made  this  impracticable, 
the  milk  was  delivered  at  the  school  by  special  ar- 
rangement and  served  by  the  class  teacher.  Each 
child  brought  his  own  cup  from  home,  and  these  were 
kept  in  one  of  the  class-room  cupboards,  and  washed 
after  school  by  one  of  the  janitor's  assistants.  This 
cooperation  on  the  part  of  the  Nathan  Straus  milk 
depot  made  it  possible  to  serve  really  delicious  milk 
at  a  nominal  cost.  The  expense  was  partly  met  by 
the  children  who  paid  a  cent  a  day  for  it.  For 
many  this  was  their  first  experience  with  milk  as  a 
cool  and  palatable  beverage.  Several  of  the  mothers 
had  fears  as  to  its  safety  and  healthfulness,  and  were 
reassured  only  with  difficulty;  but  it  soon  became 
popular  with  the  children.  Although  adding  only 
about  150  calories  to  the  daily  intake,  it  proved  a 
most  satisfactory  solution  of  the  mid-morning  lunch 
problem  for  this  group  of  children.  Mid-afternoon 
nourishment  was  provided  at  home  by  the  mothers. 

Rest. — As  in  the  fifth  grade  class  of  the  previous 
year,  rest  periods  were  taken  in  the  seats  for  a 


DEVELOPMENT  OF  PROCEDURE  103 

few  minutes  each   day  under  the  class  teacher's 
supervision. 

The  double  session  schedule  necessitated  a  noon 
period  of  an  hour  and  a  half  for  children  of  the 
X-school,  to  which  the  nutrition  class  belonged,  and 
as  all  the  children  lived  in  the  near  neighborhood, 
rest  periods  of  from  twenty  to  thirty  minutes  at 
home  were  advised.  Owing,  however,  to  congested 
home  conditions  mothers  found  this  too  difficult  a 
task  to  accomplish  with  any  degree  of  regularity. 

FEBRUARY  ENTRANTS 

The  group  of  19  children  recruited  from  those 
found  underweight  among  the  entrants  to  the  first 
grade  at  the  beginning  of  the  second  term,  was  not 
segregated  as  the  September  group  had  been  be- 
cause, even  after  the  addition  of  5  boys  from  the 
September  group  who  failed  of  promotion,  their 
total  number  (19)  was  too  small  to  organize  an  entire 
class  for  them.  They  were  divided  between  the  two 
first  grade  classes  enrolled  in  February,  and  the 
nutrition  worker  was  assigned  a  weekly  period  in 
each  class.  On  alternate  weeks  when  the  group  in- 
struction w^as  given  and  stories  told,  all  the  pupils 
in  the  room  shared  in  the  experience.  Thus,  for 
the  first  time  the  children  of  the  control  group, 
and  members  of  the  class  who  were  not  subjects  of 
special  care  or  study,  were  included  in  this  part  of 
the  nutrition  program. 

Mid-morning  milk  was  provided  for  the  children 
of  the  nutrition  group  only  and  they  were  excused 
from  their  owti  class-rooms  for  a  fifteen-minute 
period  each  morning  to  get  it.     It  was  served  in 


104  HEALTH  EDUCATION 

one  of  the  open-air  class-rooms  at  the  same  time 
that  the  open-air  boys  received  their  mid-session 
luncheon. 

Home  Cooperation 

The  attempt  to  secure  the  attendance  of  mothers 
at  the  weekly  class  sessions  was  definitely  abandoned 
at  the  beginning  of  the  year,  as  we  felt  that  without 
far  more  energy  and  time  than  we  had  at  our  dis- 
posal, we  could  not  present  a  claim  sufficiently  im- 
portant to  outweigh  the  pressure  of  work  for  a  large 
family,  the  demands  of  the  shop  or  push-cart,  or  the 
inertia  incident  to  a  foul  environment.  A  monthly 
mothers'  meeting  was  tried  as  a  substitute,  in  the 
belief  that  the  greater  convenience  and  attractive- 
ness of  a  meeting,  arranged  at  less  frequent  inter- 
vals, and  entirely  with  a  view  to  adult  interests, 
would  make  a  stronger  appeal,  but  the  relative  suc- 
cess that  followed  this  change  was  due  to  other  fac- 
tors as  well.  It  seems  reasonable  to  believe  that 
results  of  our  attempts  in  the  two  previous  years 
to  enlist  interest  and  confidence  were  beginning  to  be 
felt  in  the  community ;  in  addition,  the  general  health 
propaganda  stimulated  by  the  war  may  have  perme- 
ated the  neighborhood  sufficiently  to  have  had  an 
efifect.  Then  too,  the  mothers  of  first  grade  children 
form,  in  many  respects,  an  ideal  group  to  be  ap- 
proached. Many  of  them  have  small  families  and 
are  launching  a  child  for  the  first  time  on  his  school 
career.  Some,  through  the  kindergarten,  have 
already  made  social  contact  ^^ni\\  the  school  a  fa- 
miliar experience.  Moreover,  the  type  of  mother 
represented  in  this  group  has  not  yet  resigned  her 


DEVELOPMENT  OF  PROCEDURE  105 

child  to  outside  influences  to  any  such  degree  as  she 
tends  to  do  later  on.  Many  still  hold  rather  freshly 
in  mind  the  precepts  received  through  the  baby 
clinic  and  the  prenatal  work  of  welfare  workers,  and 
it  is  thus  relatively  easier  to  get  attention  on  mat- 
ters of  growth  and  development  at  this  period  than 
later  on. 

The  factors  working  for  increased  cooperation 
were  apparent  early  in  the  fall  when  parents  were 
asked  to  be  present  for  the  physical  examinations. 
Twenty-one  mothers  and  two  fathers  responded, 
60.5%  of  the  thirty-eight  requests  sent  out  at  that 
time.  Later  in  the  term  when  stool  and  urine  ex- 
aminations were  undertaken,  34  specimens  or  58.6% 
of  the  number  requested  were  brought  to  the  school 
at  the  appointed  time. 

mothers'  meetings 

Postal  cards  sent  to  all  the  mothers  of  the  first 
grade  nutrition  class  announced  the  first  mothers* 
meeting,  and  stated  that  the  school  desired  to  see 
present  every  mother  who  was  interested  to  cooper- 
ate with  us  in  a  special  health  program.  The  re- 
sponse was  felt  to  be  encouraging,  as  nearly  half  the 
number  were  present  at  the  first  meeting.  It  was 
held  in  the  eye  clinic  room.  The  large  individual 
charts  were  hung  against  the  black-boards,  and  these 
were  explained  to  each  mother  separately  before 
the  meeting.  This  gave  a  pleasant  informality  at 
the  start.  As  it  seemed  important  for  the  mothers 
to  realize  that  our  work  held  a  real  place  on  the 
school  program.  Dr.  Marks,  the  Principal,  was  pres- 
ent at  this  first  meeting  and  at  our  request  outlined 


106  HEALTH  EDUCATION 

for  them  the  need  for  the  work,  the  opportunity 
that  the  school  was  offering,  and  their  responsibility 
for  any  success  that  the  new  class  might  achieve. 
This  he  did  skilfully  and  aroused  a  sense  of  pride 
in  the  venture  that  carried  throughout  the  entire 
year.  The  nutrition  worker  in  charge  then  pre- 
sented a  few  of  the  specific  objectives  for  which  we 
expected  to  work,  and  for  the  attainment  of  which 
the  help  of  the  home  was  essential.  As  a  result  there 
was  a  promise  to  stand  by  us,  and  we  felt  at  the 
end  of  the  year  that  the  interest  stimulated  at  this 
initial  meeting  had  been  really  well-sustained 
throughout  the  period. 

The  meetings  were  held  each  month  from  October 
to  June  with  an  average  attendance  of  a  third  of 
the  group.  The  women  responded  to  notifications 
with  very  little  special  pleading  on  our  part.  Dr. 
Marks  or  his  assistant  usually  attended,  and  the 
class-room  teacher  was  always  present  and  met  the 
mothers  informally  after  each  session. 

Attendance  cards  were  distributed  and  consider- 
able pride  Avas  shown  in  presenting  them  to  be 
punched.  At  the  last  meeting  several  prizes  were 
given  to  those  having  the  best  showing  on  the  cards. 

In  formulating  a  program  for  these  meetings  we 
aimed  to  create  a  background  of  knowledge  regard- 
ing bodily  processes  explaining  the  reasons  for  our 
concern  with  the  underweight  child.  We  took  up 
for  discussion  simple  matters  of  personal  hygiene, 
more  or  less  familiar  in  the  abstract,  but  which  we 
knew  often  failed  to  function  in  action,  because  of 
entire  lack  of  understanding  of  the  body  mechanism 
and  the  laws  governing  growth.    The  exhibit  of  food 


DEVELOPMENT  OF  PROCEDURE  107 

models  was  used,  and  the  stories  told  the  children 
were  occasionally  retold  to  the  mothers,  with  a  view 
to  informing  them  in  regard  to  the  class-room  in- 
struction. We  were  careful  to  attack  only  one  im- 
portant matter  at  a  time,  and  much  important 
ground  was  thus  left  uncovered  at  the  end  of  the 
year.  The  following  topics  were  discussed  with  the 
mothers'  group: 

Milk:  an  essential  food  for  the  growing  child. 

Sleep:  why  the  young  child  needs  more  sleep  than  the  adult; 
the  conditions  most  advantageous  for  sleep,  and  their  value  to  all 
the   family. 

Food:  what  kinds  are  best  for  children;  how  best  prepared  and 
served;  purpose  of  the  different  kinds  of  foods. 

Health  Habits:  water  drinking,  its  use  and  abuse;  need  of 
establishing  slow  eating  and  thorough  chewing;  elimination  of  worry 
and  emotional  disturbance  at  table;  need  of  daily  rest  period,  with 
emphasis  on  its  desirability  before  eating;  need  of  securing  regu- 
larity of  stool,  and  conditions  necessary  to  obtain  this,  bad  results 
of  depending  on  the  use  of  cathartics  or  enemata;  results  of  stool 
and  urine  examinations  explained. 

Dental  Care:  the  need  for — emphasis  on  the  treatment  of  the 
first  teeth. 

As  the  year  progressed  the  members  of  our  staff 
became  increasingly  aware  of  appreciable  results 
due  in  part  at  least  to  these  discussions  at  the 
mothers'  meetings,  among  them  the  following:  (1) 
Increased  interest  in  milk-drinking.  The  frequent 
remark  which  we  had  at  the  beginning,  ''My  child 
won't  drink  milk,"  was  very  soon  replaced  by  the 
announcement  that ' '  Maxie  must  have  his  penny  now 
every  day  for  milk,"  or  ''He  loves  now  to  drink 
milk;  I  must  buy."  (2)  More  use  of  cereal  foods 
and  green  vegetables.  (3)  Attempts  in  a  few  cases 
to  supervise  a  daily  rest-period  and  in  general  an 


108  HEALTH  EDUCATION 

increase  in  the  number  of  children  put  earlier  to 
bed.  (4)  The  excellent  returns  in  securing  the  stool 
and  urine  specimens. 

Throughout  the  year  home  visiting  was  continued 
and  no  attempt  was  made  to  curtail  this  part  of  the 
nutrition  worker's  program.  The  average  number 
of  visits  paid  each  family  was  five,  but  when  children 
were  recommended  for  the  correction  of  defects,  the 
number  was  often  considerably  increased.  Data  on 
family  measurements  of  weight  and  height  were 
gathered  during  the  home  visits.  This  was  a  matter 
of  interest  to  all  members  of  the  family,  and  24 
fathers,  representing  41%  of  the  families,  were  in- 
terviewed on  the  subject  in  their  homes  by  the 
nutrition  worker.  The  considerate  attention  paid 
the  mother  by  the  Bureau  physician  at  the  time  of 
the  physical  examination  did  much  to  establish  con- 
fidence at  the  outset,  and  the  weekly  slips  sent  to  the 
homes  reporting  the  results  of  weight-taking,  con- 
tributed materially  to  sustaining  interest. 

CORRECTION   OF  DEFECTS 

Twenty-one  of  the  58  children  given  physical  ex- 
aminations, or  43.5%  of  the  total  enrolled,  were 
recommended  for  tonsil  or  adenoid  operations.  Ten 
cases  were  recommended  for  operation  in  the  fall. 
At  the  same  time  eleven  more  were  recommended 
for  observation  and  of  these,  all  were  recommended 
for  operation  in  March.  These  recommendations 
came  too  late,  however,  to  secure  necessary  arrange- 
ments before  the  end  of  school  and  therefore  the 
total  number  operated,  8  cases,  was  relatively  small, 


DEVELOPMENT  OF  PROCEDURE  109 

only  38%  per  cent  of  the  number  recommended.  The 
Post-Graduate  Hospital  received  them. 

The  record  for  dental  work  was  far  better,  as  45 
of  the  48  children  enrolled  in  the  September  group 
were  examined  and  38  or  65.5%  were  treated,  10 
by  the  family  dentist.  The  remainder  were  taken 
to  the  Stuyvesant  Clinic  or  were  treated  by  Dr.  L. 
A.  Leichter,  a  dentist,  whose  office  adjoined  the 
school  and  who  generously  offered  to  give  his  ser- 
vices, but  in  accordance  with  a  suggestion  from  our 
staff  decided  to  ask  a  nominal  fee.  A  developing 
disposition  on  the  part  of  the  parents  to  pay  the 
fees  was  one  of  the  most  encouraging  features  of 
the  year's  experience.  Fourteen  mothers  paid  the 
fees  for  dental  treatment  in  full;  others  paid  in 
part.  The  total  work  done  amounted  to  76  fillings 
and  74  extractions. 

It  was  found  impossible  to  carry  out  recommenda- 
tions for  correction  of  defects  found  among  the  little 
group  enrolled  in  February.  As  we  were  unable 
to  begin  the  nutrition  procedure  for  them  until 
March,  the  period  available  was  too  brief  to  secure 
the  necessary  permissions  from  parents,  and  obtain 
appointments  at  the  various  crowded  clinics. 

Physical  Examinations 

Of  the  58*  physical  examinations,  43  were  done 
by  the  Bureau  physician  and  15  by  Dr.  I.  H.  Gold- 
berger,   a   physician   of  the   Board   of  Education. 

*  Of  the  total  number  (62)  enrolled  during  the  year,  4  were  trans- 
ferred before  physical  examinations  had  been  made;  thus  the  tabu- 
lations in  Dr.  Lincoln's  report  are  for  a  total  of  58. 


110  HEALTH   EDUCATION 

Partial  reexaminations  were  done  by  the  Bureau 
physician  on  11  cases. 

The  mother  was  usually  present  at  the  examina- 
tion and  was  encouraged  to  ask  questions  regarding 
the  child,  and  a  short  interview  was  usually  given 
at  the  close  of  the  physical  examination,  giving  re- 
sults of  the  examination  and  recommendations. 
Occasionally,  in  order  to  stimulate  the  confidence  of 
the  mother,  advice  about  her  own  condition  was 
given  when  requested. 

As  complete  a  general  physical  examination  as 
possible  was  given  to  each  child,  consuming  on  the 
average  half  an  hour,  including  otoscopic  examina- 
tion and  rough  hearing  tests.  No  eye  examination 
beyond  the  usual  routine  was  done,  as  all  these  chil- 
dren were  examined  in  the  eye  clinic  of  the  Board 
of  Health  in  whose  room  the  physical  examinations 
took  place. 

No  attempt  was  made  to  diagnose  tuberculosis 
except  on  physical  signs.  The  only  case  suspicious 
of  pulmonary  tuberculosis  was  referred  to  the  chil- 
dren's tuberculosis  clinic  at  Bellevue  Hospital,  and 
was  taken  there  by  one  of  the  nutrition  workers  for 
x-ray  and  the  von  Pirquet  test.  No  other  tuberculin 
tests  were  made. 

Besides  the  routine  examinations  of  the  heart, 
exercise  tolerance  tests  were  occasionally  done  on 
suspicious  cardiacs.  One  case  diagnosed  as  cardiac, 
and  one  suspected  case  were  cardiographed  at  Belle- 
vue Hospital  by  Dr.  Kelley. 

Stool  examination  was  done  on  47  cases  and  urine 
examination  on  49  out  of  58  children.  These  were 
added  in  the  first  place  as  further  means  of  diag- 


DEVELOPMENT  OF  PROCEDURE  111 

nosis,  and  proved  of  particular  value  for  convincing 
the  mother  in  cases  where  corrective  dietetic  meas- 
ures were  indicated.  An  undernourished  child, 
whose  mother  is  concerned  about  his  condition,  is 
apt  to  receive  extra  rations  of  food  considered  fat- 
tening, especially  carbohydrates,  but  often  in  the 
cases  of  the  Jewish  children  studied,  an  attempt  is 
made  to  add  to  the  diet  by  giving  cream  with  food, 
or  even  as  a  beverage.  Obviously  where  there  is 
faulty  digestion  of  any  one  food  component  and 
particularly  in  the  case  of  fats,  no  good  and  pos- 
sibly harm  can  be  done  by  overfeeding  this  element 
of  the  food. 

In  addition  to  the  large  number  of  cases  of  con- 
stipation, 22  out  of  47,  5  cases  of  fermentation  were 
found,  large  numbers  of  undigested  starch  cells  in 
11  cases,  of  undigested  muscle  fibres  in  8  cases,  and 
a  large  amount  of  neutral  fat  in  3  cases. 

Since  no  second  examinations  were  made,  it  is 
recognized  that  these  results  are  not  unimpeachable ; 
but  at  least  they  are  very  suggestive,  and  corrective 
dietetic  measures  were  instituted  in  the  cases  of  fer- 
mentation and  fatty  indigestion  and  constipation, 
because  of  the  large  proportion  of  cases  confirmed 
by  stool  examination. 

It  was  decidedly  a  surprise  to  find  all  the  stools 
negative  for  ova  and  parasites  on  routine  examina- 
tions. Oscar  M.  Schloss  *  in  consecutive  examina- 
tions of  the  stools  of  280  children  found  parasites 
or  ova  in  28.5%,  78%  of  the  positive  cases  being  in 
children  over  five  years  of  age.    For  this  reason  a 

*  Schloss,  Oscar  M.,  American  Journal  of  Medical  Science,  May, 
1916. 


112  HEALTH  EDUCATION 

second  examination  was  made  in  10  cases  taken  with- 
out selection  from  the  nutrition  group.  Stools  from 
these  cases  were  examined  by  the  Loop  Flotation 
Brine  method  of  Kof  oid  and  Barber,*  this  being  the 
method  used  in  the  army  in  search  for  parasites  and 
ova.f  All  these  stools  were  again  negative. 

Urine  examinations  were  negative  in  48  out  of 
49  cases,  albumen  being  present  on  one  occasion  in 
one  specimen.  They  were  therefore  not  nearly  so 
suggestive  nor  helpful  as  stool  examinations. 

Owing  partly  to  the  difficulties  encountered  in  the 
examining  room,  due  to  its  size,  proximity  to  street 
noises,  and  numbers  of  mothers  and  children  wait- 
ing for  examination,  a  good  many  discrepancies  and 
omissions  occur  on  the  charts.  They  cannot  there- 
fore be  used  to  obtain  exact  statistics  regarding 
presence  or  absence  of  abnormalities  in  this  group 
of  undernourished  children.  In  some  instances,  how- 
ever, the  records  are  fairly  complete,  as  on  teeth, 
where  note  of  some  kind  has  been  made  on  each  child 
examined,  even  if  the  number  of  decayed  teeth  has 
not  been  mentioned. 


No.  of 

Muscle  Tone:     Cases  % 

Firm 13  22.4 

Fair 19  32.7 

Flabby 21  36.2 

Very  flabby 1  1.7 

Not  noted 4  7.0 


No.  of 
General  Condition  :Cases     % 

Good 13      22.4 

Fair 14       24.1 

Poor 

8       13.8 

Not  noted 

23      39.7 

Total 

58     100.0 

Total 58     100.0 

*  Kofoid  and  Barber,  Journal  of  the  American  Medical  Society, 
Vol.  LXXI,  p.  1557. 

t  Kantor,  Journal  of  the  American  Medical  Society,  July,  1919. 


DEVELOPMENT  OF  PROCEDURE 


113 


No.  of 
Breathinq:  Cases      % 

Obstructed 9       15.5 

Partially  obstructed ...   2 1       36 . 2 

Free 22      38.0 

Not  noted 6      10.3 

Total 58    100.0 


No.  of 

Cases 
.     2 
.    12 


% 

3.4 

20.7 


Tonsils: 

Complete  removal.  . . 

Apparently  normal.. . 

Moderate  enlargement 
only 8       13.8 

Very  large  or  with  evi- 
dences of  disease ...   36      62 . 1 

Total 58     100.0 


No.  of 

Teeth:                   Cases  % 

One  or  more  decayed . .  52  89 . 7 

None  decayed 6  10.3 

Total 58  100.0 

No.  of 

Approximation     Cases  % 

Good 27  46.6 

Fair 8  13.8 

Poor 9  15.5 

Bad 1  1.7 

Not  noted 13  22.4 

Total 58  100.0 

No.  of 

Ears:                     Cases  % 

Drums— Normal 22  38.0 

Thickened...   17  29.2 
Otherwise  dis- 
eased      7  12.1 

Not  seen 7  12.1 

Not  noted...     5  8.6 

Total 58  100.0 


No.  of 

Glands:         Cases  % 
No     enlargement     of 

glands 4  7.0 

Moderate  enlargement  38  65.4 

Marked  enlargement . .   16  27.6 

Total 58    100.0 

Note. — Marked  enlargement  in- 
cludes both  general  glandular  en- 
largement and  marked  enlarge- 
ment of  a  single  group  of  glands. 
Thyroid  was  palpable  in  one  case 
only. 


No.  of 

Eyes:                     Cases  % 

Normal 30  51.7 

SI.  conjunctivitis 14  24.1 

Conjunctivitis 3  5.2 

Marked  conjunctivitis.     2  3.4 

Strabismus 2  3.4 

Stye 1  1.7 

Blepharitis..! 3  5.2 

Sluggish    reaction     to 

light 1  1.7 

Not  noted 3  5.2 


114 


HEALTH  EDUCATION 


No.  of 

Heart:                  Cases  % 

Normal 50  86.2 

Poor  muscle  sounds ...     2  3.4 

Organic  murmurs 3  5.2 

.  Enlargement 3  5.2 

Diag.  of  cardiac  disease    2  3.4 

No.  of 
D'EspiNB  Sign  :      Cases     % 

Negative 35  60 . 3 

Positive 23  39.7 

Total 58  100.0 


No.  of 
Abdomen:  Cases 

Normal 36 

Prominent 13 

Hernia  or  enl.  ring. ...   10 
Umbilical  hernia.  2 
Inguinal  hernia. .  8 
Lax  muscles 1 

No.  of 
Extremities:        Cases 

Normal 22 

Enlarged  epiphyses ...      1 

Knock  knees 23 

Bowing  of  tibiae 1 

Hyperactive  reflexes.  .   17 

Ejiee  jerks 16 

Upper  reflexes. . .     1 

Babinski 2 

Edema 1 


% 
62.1 
22.4 
17.3 


1.7 


% 
37.9 

1.7 
39.7 

1.7 
29.3 


3.4 
1.7 


No.  of 

Lungs:  Cases  % 

Normal 52  89.7 

Bronchitis 4  6.9 

SI.  impairment 2  3.4 

Total 58    100.0 


Note. — D'Espine  Sign  has  been 
considered  positive  where  in- 
creased whispered  voice  was 
heard  at  or  below  the  third  dor- 
sal vertebra.  There  were  5 
cases  not  heard  below  the  third. 

No.  of 

Genitals  ;              Cases  % 

Normal 45  77.6 

Undescended  testicles  .10  17.3 

Phimosis 2  3.4 

Other  condition 1  1.7 

Total 58    100.0 

V      No.  of 

Skin:  Cases  % 

Normal 50  86.4 

Pediculosis 2  3.4 

Scabies 1  1.7 

Alopecia  areata 1  1.7 

Not  diagnosed 2  3.4 

Not  noted 2  3.4 

Total 58    100.0 


DEVELOPMENT  OF  PROCEDURE 


115 


No.  of 

Mucous  Membrane  :Cases     % 

Good  color 

19      32.7 

Fair  color 

12      20.7 

Pale   

20      34 . 5 

Not  noted 

7       12.1 

Total 58    100.0 


No.  of 

Chest:                 Cases  % 

Normal 26  44.8 

Harrison's  groove: 

Slight  or  moderate..  20  34.5 

Marked 4  6.9 

Depressed  sternum.  .  .   11  19.0 

Rosary 3  5.2 

"Rachitic" 1  1.7 

Flat 2  3.4 

Narrow 1  1.7 


No.  of 


No.  of 


No.  of 


Spine:  Cases      %         Feet:  Cases      %        Posture:  Cases      % 


Kyphosis . .  5 
Scoliosis . .  3 
Lordosis. . .  3 
Normal.  .  .47 


8.6 

5.2 

5.2 

81.0 


Normal.. 
Weak... 


33 
25 


56.9 
43.1 


Poor 11 

Good 5 

Not  noted  42 


19.0 

8.6 

72.4 


Total.   58    100.0 


Total.  .  58    100.0 


Total...  58    100.0 


No.  of 
Stool  Examination:  Cases 

Not  examined 11 ' 

Normal 15 

Constipated 22 

Fermentation 5 

Many  imdigested  starch  and  vegetable  cells .   11 

Many  undigested  meat  cells 8 

Much  free  fat  and  many  fatty  acid  crystals .     3 
Ova  and  parasites  not  found. 


% 
19.0 
25.9 
38.0 

8.6 
19.0 
13.8 

5.2 

No.  of 


Urine: 


Small   amount   of 
mucus 6 

Albumen  on  one  occa- 
sion       1 

Not  examined 9 


No.  of 

Cases       %        Electrocardiograms:  Cases  % 

1 

1 


Normal 48      82.8    Slight  left  preponderance.   1 


Right  preponderance  with 
poor  muscle  tone 1 


1.7 
15.5 


Total 58    100.0 


116 


HEALTH  EDUCATION 


Recommendations 


No.  of  Cases 


Per  Cent 


Dental  care 

Removal  of  jaw  polyp 

Tonsillectomy  and  adenoidectomy  or  ade- 

noidectomy  alone 

Observation  of  nose  and  throat 

Eye  examination 

Treatment  scabies 

Cardiac  precautions 

X-ray  chest  advised 

Circumcision 

Observe  testicles 

Observe  hernia 

Foot  exercises 

Other  corrective  measures 

Attention  to  posture,  including  exercises 

Dietetic  advice 

Tonics  given 

General  hygiene 

Hygiene  for  eneuresis 

Observe  for  achondroplasia 


52 
1 

20 

20 

9 


89.7 
1.7 

34.5 
34.5 
15.5 

1.7 


2 

3.4 

1 

1.7 

1 

1.7 

4 

6.9 

1 

1.7 

20 

34.5 

1 

1.7 

4 

6.9 

3 

5.2 

2 

3.4 

1 

1.7 

1 

1.7 

1.7 


DEVELOPMENT  OF  PROCEDURE 


117 


September  and  February  Nutrition  Groups 
Per  Cent  Underweight  of  Children  xoith  Physical  Defects 


First  Weighing 

Last  Weighing 

No.of 

Cases 

Av.  % 
Under- 
weight 

P.E. 

Av.% 
Under- 
weight 

P.E. 

P.E.D. 

D 

FED. 

Fermentation 

Poor  general  condi- 
tion   

5 

9 
22 

17 
10 
36 

22 
24 

14.40 

10.88 
11.77 

9.41 
10.40 
10.64 
10.09 
11.04 

1.232 

.4284 
.5415 

.4946 
.4061 
.3040 
.3394 
.3329 

10.20 

9.00 
8.95 

6.59 
5.70 
7.33 
5.82 
5.58. 

1.568 

.5510 
.5974 

.5676 
.7067 
.4743 
.5600 
.5198 

1.994 

.6979 
.8062 

.7528 
.8150 
.5633 
.6547 
.6172 

2.106. 
2.693 

Poor  muscle  tone .  . 
Hyperactive        re- 
flexes  

3.495 
3.750 

Decayed  teeth .... 
Diseased  tonsils . . . 

Constipation 

Harrison's  groove. 

5.766 
5.876 
6.527 
8.843 

Sept.  and  Feb.  nu- 
trition groups.  . . 

58 

11.20 

.2880 

7.37 

.3769 

.4743 

8.077 

CHAPTER  VI 

GROWTH  IN  WEIGHT  AND  HEIGHT 
First  Grade  Children 

SELECTION 

The  total  number  of  entrants  to  the  first  grade 
classes  of  Public  School  64,  in  September,  1919,  were 
weighed  and  the  height  measured.  One  hundred 
and  twenty-three  of  these  boys  were  measured  be- 
tween September  9th  and  September  24th.  Two 
entered  in  October  and  one  in  November,  making 
126,  from  whom  the  Nutrition  Class  was  selected. 
Forty  boys,  ranging  from  87c  to  20 7o  underweight 
for  height,  and  with  an  average  per  cent  underweight 
of  11.6,  were  segregated  in  this  class.  The  early 
transfer  of  2  boys  reduced  the  group  to  38.  Of  the 
boys  weighed  after  September  18th,  ten  were  found 
to  be  more  than  S%  underweight.  By  the  first  of 
December,  four  of  these  had  entered  the  Nutrition 
Class  to  replace  members  who  had  been  transferred 
to  other  schools,  and  in  February,  1920,  four  more 
entered  to  replace  boys  who  were  not  promoted  with 
the  group.  The  other  two  underweight  boys  are 
tabulated  with  the  general  group. 

A  Control  Group  was  formed  of  those  nearest  the 
normal  standards  for  height-weight  index  at  their 
ages.  There  were  found  41  boys  who  ranged  from 
4%  above  to  4%  below  normal  weight  for  height, 

118 


GROWTH   IN   WEIGHT  AND   HEIGHT       119 

and  6  boys  from  5%  above  to  87c  below  normal.  The 
last  case  was  included  in  the  Control  Group  through 
error  in  first  calculation.  The  average  per  cent 
underweight  of  this  group  was  0.83. 

Measurements  were  taken  without  shoes  or  coats. 
The  Nutrition  Group  was  weighed  weekly  from 
September  to  June,  and  the  height  was  measured 
monthly.  The  Control  Group  was  measured  every 
two  months  and  the  others  of  the  general  group,  not 
included  in  these  two  classes,  were  measured  again 
in  May,  1920. 

The  chronological  age  of  the  Nutrition  Group 
ranged  from  5.25  to  7.39  years,  with  an  average  of 
6.3  years.  The  range  for  the  Control  Group  was 
5.96  to  7.54  years,  mth  an  average  of  6.3  years.  The 
nationalities  represented  were  as  follows : 

Nutrition  Grodps 
September  1919  Group 

Russian 25        79|%  Russian  and  Austrian 

Austrian 10 

Italian 2 

Galician 1 

Hungarian 4 

Rumanian 1 

German  Jew 1  (Born  N.  Y.  C.) 

February  1920  Group 

Russian 6        79%  Russian  and  Austrian 

Austrian 5 

Hungarian 1 

German  American 1 

Irish  American 1 

In  February,  58  boys  entered  the  first  grade 
classes.  They  were  measured  and  a  group  of  14, 
ranging  from  7%  to  22%  underweight,  was  formed 


120  HEALTH  EDUCATION 

on  March  2.  Five  boys  of  the  September  class,  who 
failed  of  promotion,  were  placed  with  this  group. 
Twenty-three  entered  school  during  March  and 
April,  and  of  these  7  ranged  from  8%  to  12%  under- 
weight. Twenty-two  boys  of  the  February  entrants 
formed  a  Control  Group,  ranging  from  4%  above  to 
4%  below  normal  standards.  These  mid-year  en- 
trants were  not  segregated  into  groups,  but  divided 
between  two  class-rooms. 

DISTRIBUTION  OF  PERCENTAGES  OVER  AND  UNDERWEIGHT 

Chart  I  represents  the  distribution  of  the  percent- 
ages over  and  underweight  for  all  the  children  who 
entered  the  first  grades  in  September,  1919.  Of  126 
children,  measured  at  entrance  in  the  fall,  8  were 
of  normal  height  and  weight ;  of  the  remaining  118, 
25  or  21%  were  from  1-24%  overweight  and  93  or 
79%  were  from  1-24%  underweight;  55  children  or 
43.7%  were  from  8-24%  underweight,  6  children  or 
4.8%  were  from  16-24%  underweight.  Contrasted 
mth  these  we  have  only  6  children  or  4.8%  who  were 
from  8-24%  overweight,  2  children  or  1.6%  who  were 
from  16-24%  overweight. 

There  were  81  boys  entering  in  February  and 
March.  Of  these  10  were  of  normal  w^eight  for 
height,  29  were  from  1-24%  overweight,  16  were 
from  1-6%  underweight,  and  26  were  from  7-22% 
underweight. 

If  we  take  a  seven  per  cent  standard  for  select- 
ing the  undernourished  child,  and  if  we  consider 
this  general  group  a  typical  one  for  the  age,  sex, 
stock  and  social  group  studied,  we  find  nearly  50% 


GROWTH  IN  WEIGHT  AND  HEIGHT       121 


is 


w 

o 

l-H 


CO 

O 
< 

o 

o 
o 

M 

H 

M 
H 

CO 


w 


04 

o 


05  3  a 

H    -<!  W 

Q    »^  H 

►§«  a 


o 
o 


5   f^ 


O 

a 

w  2 
S  O 


05    S 


122  HEALTH  EDUCATION 

or  half  of  them  are  undernourished  when  meas- 
ured in  September;  a  little  more  than  25%  or  a 
fourth  are  undernourished  when  measured  in  Feb- 
ruary. The  seasonal  variations  shown  in  all  the 
groups  studied  would  account  for  this  difference  in 
percentage  between  September  and  February.  The 
large  percentage  found  for  the  September  group  in- 
dicates need  of  more  careful  determination  of  the 
criteria  of  malnutrition  or  undernourishment. 

The  children  of  the  September  Nutrition  Group 
averaged  11.56%  underweight  at  the  first  measuring, 
the  range  being  from  8-20%  underweight.  The  Con- 
trol Group  averaged  0.83%  underweight  at  that  time, 
with  a  range  from  8%  under  to  5%>  overweight.  The 
wide  variation  between  these  two  averages  and  the 
fact  that  the  average  percentage  underweight  of  the 
Control  Group  so  nearly  approximates  zero  would 
seem  to  indicate  that  likenesses  or  differences  be- 
tween these  groups  are  significant  ones  and  are  not 
due  to  faulty  selection  from  the  standpoint  of  nu- 
tritional status.  However  the  demarcation  of  8% 
under  for  a  Nutrition  Group  is  not  established,  and 
the  nutritional  behavior  of  the  children  in  both 
groups  near  this  borderline  should  help  to  deter- 
mine standards  of  malnutrition. 

The  accompanying  tables,  la  and  lb,  show  the  per- 
centages underweight  of  the  September  Nutrition 
and  Control  Groups  for  October,  December,  Febru- 
ary, April,  and  June,  according  to  the  Burk-Boas 
norms  of  weight  for  height.  These  percentages  are 
derived  from  a  height  and  a  weight  taken  on  the  same 
day,  this  day  falling  for  a  given  month  between  the 


GROWTH  IN  WEIGHT  AND   HEIGHT       123 

8th  day  of  that  month  and  the  8th  day  of  the  preced- 
ing month.  For  example,  the  percentages  underweight 
for  October  are  based  on  a  height  and  a  weight  meas- 
ured for  any  one  individual  on  the  same  day,  this 
day  falling  between  September  8th  and  October  8th, 
etc. 

COMPAEISON  OF  UNDERWEIGHT  AND  CONTROL  GROUPS 

The  total  gain  in  weight  is  reckoned  from  the  time 
the  individual  entered  the  Nutrition  or  the  Control 
Class  until  approximately  June  1st,  when  the  last 
weighing  was  made,  and  includes  those  individuals 
who  missed  not  more  than  four  weekly  weighings 
either  at  the  beginning  or  the  end  of  a  period  of 
eight  months,  during  which  the  class  was  conducted. 
The  deviations  from  normal  gain  are  given  for  these 
same  individuals  and  are  obtained  by  subtracting 
the  total  gain  in  weight  from  the  normal  gain  for 
eight  months,  as  given  by  Burk  and  Boas. 

Similarly,  Table  II  contains  percentages  for  the 
minor  groups,  selected  in  the  following  February, 
for  February,  April  and  June,  the  measurements 
being  made  between  the  20th  of  the  given  month  and 
the  20th  of  the  preceding  month.  The  gains  in 
weight  are  given  for  the  children  who  missed  not 
more  than  two  weekly  weighings  either  at  the  begin- 
ning or  the  end  of  the  class  period.  The  deviation 
from  normal  gain  is  obtained  by  subtracting  the 
total  gain  for  the  class  period  from  the  normal  gain 
for  four  months,  as  given  by  Burk  and  Boas. 

The  Total  Gain  for  the  Nutrition  Group  (Table 
la)  during  the  class  period  shows  an  average  of  3.69 


124 


HEALTH  EDUCATION 


TABLE  I  a 

Percentage  Underweight 
September  Nutrition  Group 


No. 

October 

December 

February 

April 

June 

Total  Gain 
(lbs.) 

Dev.  from 

Normal 

Gain 

+      - 

+      - 

+      - 

+      - 

+      - 

+        - 

+        - 

1 

10 

5 

5 

8 

8 

2.7 

0.1 

2 

11 

7 

4 

3 

10 

3 

5 

5 

4.2 

1.4 

4 

11 

7 

7 

4 

8 

4.0 

1.1 

b 

9 

6 

8 

0 

4 

0 

2 

4.8 

1.9 

7 

7 

4 

7 

8 

11 

4 

2 

6 

4.0 

1.0 

9 

12 

10 

8 

6 

6 

3.9 

0.8 

10 

12 

7 

2 

7 

7 

3.6 

0.6 

11 

9 

12 

14 

7 

7 

7 

9 

2.7 

0.2 

13 

12 

7 

9 

7 

7 

4.1 

1.2 

14 

16 

9 

5 

7 

9 

3.8 

1.0 

15 

17 

9 

10 

12 

2.1 

0.7 

16 

8 

8 

8 

10 

17 

8 

4 

2 

0 

4 

5.4 

2.5 

18 

20 

14 

10 

6 

9 

6.3 

3.3 

19 

12 

5 

5 

2 

7 

1.7 

1.2 

20 

8 

6 

2 

0 

0 

5.8 

3.0 

21 

12 

4 

6 

4 

4.6 

1.8 

22 

13 

11 

9 

10 

3.1 

0.2 

23 

12 

11 

9 

9 

12 

3.2 

0.2 

24 

10 

2 

5 

2 

0 

3.0 

0.2 

25 

13 

9 

7 

10 

12 

2.0 

1.0 

26 

14 

7 

11 

9 

9 

3.1 

0.1 

27 

10 

7 

2 

2 

7 

1.4 

1.5 

28 

8 

6 

6 

2 

0 

5.1 

2.0 

29 

12 

2 

2 

0 

30 

8 

2 

6 

2 

6 

4.4 

1.6 

31 

9 

7 

4 

8 

3.4 

0.4 

32 

15 

5 

2 

2 

5 

2.6 

0.2 

33 

10 

10 

7 

9 

9 

1.9 

0.9 

34 

10 

12 

7 

2 

35 

16 

7 

9 

7 

11 

2.2 

0.9 

36 

9 

0 

4 

2 

5.1 

2.1 

37 

14 

12 

11 

9 

38 

12 

7 

5 

4 

7 

2.7 

0.3 

39 

9 

2 

2 

2 

0 

5.7 

2.9 

40 

12 

6 

6 

6 

4 

5.5 

2.3 

41 

14 

42 

12 

12 

10 

4 

9 

43 

10 

8 

10 

44 

8 

4 

6 

Av. 

-11.56 

-6.60 

-5.68 

-4.4 

-6.54 

3.69 

0.769 

a 

2.691 

3.330 

3.670 

3.217 

3.811 

1.305 

1.250 

P.E 

.2725 

.3029 

.40 

.3667 

.423 

.1552 

.1487 

GROWTH  IN  WEIGHT  AND  HEIGHT       125 


TABLE  I b 

Pebcentage  Under  or  Over  Weight 

September  Control  Group 


No. 

October 

December 

February 

April 

June 

Total  Gain 
(lbs.) 

Dev.  from 

Normal 
Gain 

+ 

- 

+      - 

+      - 

+      - 

+      - 

+        - 

+        - 

1 

4 

6 

6 

4.4 

1.6 

2 

4 

0 

0 

2 

4 

4.6 

1.6 

3 

6 

2 

2 

0 

2 

4.0 

1.1 

4 

2 

0 

2 

2 

2 

2.8 

0.0 

5 

5 

10 

7 

7 

1.2 

1.8 

6 

2 

2 

7 

5 

2 

3.5 

0.7 

7 

2 

4 

4 

3.3 

0.5 

8 

4 

0 

2 

0 

2 

3.6 

0.8 

9 

5 

0 

0 

0 

4.0 

1.1 

10 

0 

0 

2 

11 

8 

4 

2 

0 

2 

5.4 

2.4 

12 

2 

5 

2 

7 

2 

5.7 

2.8 

13 

4 

0 

2 

2 

0 

4.7 

1.9 

14 

2 

0 

2 

4 

6.9 

4.1 

15 

2 

9 

2 

2 

3.1 

1.3 

16 

4 

2 

4 

6 

2 

4.7 

1.7 

17 

7 

2 

2 

7 

7 

3.0 

1.2 

18 

2 

5 

5 

2 

2 

3.5 

0.7 

19 

5 

9 

7 

11 

4 

5.1 

2.3 

20 

2 

7 

7 

12 

7 

4.5 

1.7 

21 

2 

7 

7 

2 

8 

7.0 

4.1 

22 

2 

0 

2 

2 

2 

4.5 

1.7 

23 

0 

5 

5 

7 

24 

2 

5 

7 

7 

7 

4.3 

1.5 

25 

0 

2 

7 

2 

3.7 

0.8 

26 

4 

0 

0 

4 

2 

3.5 

0.7 

27 

2 

0 

2 

2 

4 

5.5 

2.6 

28 

4 

4 

2 

0 

0 

4.3 

1.4 

29 

2 

2 

5 

5 

5 

1.9 

0.9 

30 

4 

9 

9 

4 

6 

4.2 

1.4 

31 

2 

2 

7 

2 

3.2 

0.1 

32 

2 

2 

4 

0 

0 

3.1 

0.0 

33 

4 

4 

0 

2 

34 

0 

11 

11 

4 

35 

2 

0 

0 

0 

4 

3.2 

0.2 

36 

0 

2 

5 

10 

2 

3.7 

0.8 

37 

4 

2 

6 

2 

6.6 

3.6 

38 

2 

12 

4 

7 

0 

3.6 

0.8 

39 

4 

4 

4 

0 

3.5 

0.7 

40 

2 

5 

41 

2 

4 

8 

10 

8 

4.7 

1.8 

42 

4 

0 

2 

4 

0 

4.4 

1.2 

43 

0 

3 

5 

2 

0 

1.9 

1.1 

44 

0 

8 

10 

4 

8 

6.5 

3.4 

45 

2 

0 

2 

0 

4 

4.7 

1.9 

46 

4 

2 

2 

0 

3.9 

0.9 

47 

2 

2 

6 

2 

6 

4.8 

1.7 

Av. 

.826 

2.50 

3.21 

2.79 

2.17 

4.16 

1.3 

<r 

3 

.191 

3.864 

4.048 

4.289 

3.4.33 

1.248 

1.234 

P.E. 

.3158 

.3941 

.4372 

.4418 

.3570 

.1297 

.1283 

126 


HEALTH  EDUCATION 


TABLE  II 

Percentage  Underweight  of  February  Groups 
Nutrition  Group 


February 

April 

June 

Total  Gain 
(lbs.) 

Dev.  from 
Normal  Gain 

No. 

+ 

+ 

+ 

+ 

+ 

1 

8 

4 

8 

1.0 

0.1 

2 

22 

16 

20 

0.4 

0.7 

3 

7 

12 

8 

1.5 

0.4 

4 

10 

5 

10 

0.5 

0.7 

5 

10 

3 

10 

0.2 

0.9 

6 

11 

7 

4 

0.8 

0.3 

7 

10 

6 

0.8 

0.3 

8 

7 

9 

9 

0.4 

0.7 

9 

8 

8 

6 

0.3 

0.8 

10 

14 

15 

0.3 

0.8 

11 

11 

7 

9 

1.0 

0.1 

12 

10 

12 

0.9 

0.2 

13 

10 

10 

12 

0.0 

1.3 

14 

22 

20 

20 

0.3 

1.4 

Av. 

-11.43 

-8.92 

-11. 

0.5 

-0.564 

<r 

4.651 

4.780 

4.657 

.51.54 

.4748 

P.E. 

.8372 

.9321 

.8708 

.0927 

.0854 

Control  Group 


1 

4 

2 

2 

0.5 

1.9 

2 

7 

1.2 

0-2 

3 

2 

2 

0 

1.1 

2.5 

4 

2 

2 

7 

1.0 

2.4 

5 

0 

4 

0 

0.3 

1.1 

6 

0 

2 

2.3 

0.9 

7 

0 

4 

0 

1.3 

0.1 

8 

2 

9 

4 

2 

6 

1.4 

2.8 

10 

2 

2 

0.5 

0.9 

11 

0 

2 

2 

3.7 

2.3 

12 

2 

4 

2 

0.4 

1.0 

13 

2 

2 

8 

1.5 

3.2 

14 

2 

2 

0.8 

0.6 

15 

4 

4 

0 

1.3 

2.7 

16 

4 

2 

0.8 

0.6 

17 

2 

2 

10 

0.2 

1.6 

18 

2 

2 

0.8 

0.8 

19 

0 

2 

4 

1.0 

2.4 

20 

4 

8 

1,8 

3.2 

21 

2 

2 

0.9 

0.5 

22 

2 

2 

0.4 

1.8 

Av. 

1.00 

1.05 

-3.41 

0 

133 

-1.29 

a 

2.134 

2.460 

3.466 

1 

341 

1.356 

P.E. 

.  3393 

.3813 

.  5084 

1871 

.1993 

GROWTH  IN  WEIGHT  AND   HEIGHT       127 

lbs.  with  a  range  from  1.4  to  6.3  lbs. ;  moreover  the 
average  deviation  from  normal  gain  is  a  slightly 
positive  one,  0.769  lb.  For  the  Control  Group  the 
average  gain  in  weight  is  4.16  lbs.  with  an  average 
deviation  from  normal  gain  of  1.3. 

The  Probable  Error  of  Difference  between  the 
total  gains  of  the  groups  is  0.2022,  the  Difference 
being  2.324  times  this  Probable  Error. 

The  Probable  Error  of  Difference  between  the 
average  deviations  from  normal  of  these  groups  is 
0.1963,  the  Difference  being  2.705  times  this  Probable 
Error. 

SEASONAL   VARIATION 

Chart  2  is  a  graphic  representation  of  the  aver- 
ages in  Tables  la,  lb,  and  II,  including  an  aver- 
age obtained  for  September,  1920,  after  the  sum- 
mer vacation.  The  upward  trend  of  the  curve  indi- 
cates a  decrease  in  the  percentage  underweight,  the 
downward  trend,  an  increase  in  this  percentage.  It 
can  be  seen  that  the  September  Nutrition  Group 
shows  a  marked  rise  in  its  curve  from  October  to 
April,  which  is  indicative  of  a  rapid  reduction 
in  its  percentage  underweight,  a  reduction  from 
11.56% ±2.691  underweight  in  October  to  4.4% 
±3.217  in  April;  the  greatest  percentage  of  gain 
occurred  before  December.  This  is  followed  from 
April  through  the  following  September  by  a  drop 
in  the  curve  or  an  increase  in  percentage  under- 
weight; in  June  this  was  6.54%  and  in  September, 
1920,  8.4%. 

The  Control  Group  Curve  for  percentage  under- 


128 


HEALTH  EDUCATION 


OCT  DEC  Fta.  ATR.  JUNE  A0&  OCT. 


TETCEK-q 

4 


SETT 


•   FEB 


NUTT^ITIOM. 


•  SEPT.. 


Chart  2 
Pekcentage  Underweight — First  Grade 


GROWTH  IN  WEIGHT  AND  HEIGHT       129 

weight  follows  the  same  general  trend  except  that 
its  fluctuations  are  smaller.  Starting  at  0.83% 
underweight  in  October,  it  rises  rapidly  to  2.5% 
overweight  in  December.  In  February  it  reaches  its 
highest  point,  3.21%  overweight,  after  which  there 
is  a  decline  through  April,  June  and  September, 
when  the  group  is  2.17%  overweight. 

The  similarity  between  all  four  of  the  curves  in 
Chart  2  is  striking,  the  exception  being  that  the  Sep- 
tember Control  Group  reaches  its  highest  point  in 
February  instead  of  April,  as  is  the  case  for  the 
other  groups. 

The  averages  for  height  and  weight  contained  in 
Table  III  are  plotted  in  Chart  3,  together  with  curves 
of  growth  in  weight  according  to  the  Thomas  D. 
Wood  norms  *  and  the  Porter  norms  f  as  indicated 
by  the  dotted  line.  The  similarity  between  these 
normal  curves  and  that  of  the  Control  Group  estab- 
lishes the  value  of  the  latter  as  a  control. 

The  Weight  Curves  of  the  Nutrition  and  Control 
Groups  while  alike  in  trend  are  widely  different  in 
placement  on  the  weight  scale ;  there  is  a  difference 
of  4.99  lbs.  in  the  October  measures  and  a  difference 
of  5  lbs.  the  following  September.  The  largest  in- 
crease for  both  groups  occurs  between  October  and 
February ;  from  February  to  June  there  is  a  marked 
decrease  in  rate  of  gain  and  a  still  further  decrease 
between  June  and  September.  The  following  figures 
indicate  these  fluctuations  in  percentages: 

•  See  Wood  tables  of  height  and  weight  published  in  the  pamphlet 
by  Dr.  L.  Emmett  Holt,  Standards  of  Nutrition  and  Growth,  Child 
Health  Organization,  New  York  City. 

t  Op.  cit. 


130 


HEALTH  EDUCATION 


Chart  3 

Curves  op  Growth  in  Height  and  Weight  for  September  Nu- 
trition AND  Control  Groups,  Also  the  Normal  Weight  Curves 
of  Wood  and  Porter, 


GROWTH  IN   WEIGHT  AND   HEIGHT       131 

Gain  in  Weight 


September  Nutrition 


September  Control 


Total  Oct-Oct. 
Oct.-Feb. 
Feb -June 
June-Sept 


5.62  lbs. 

3.63  lbs.  or  64.6% 
1.02  lbs.  or  18.1% 
0.97  1b.   or  17.3% 


5.41  lbs. 

2.57  lbs.  or  47.5% 
1.55  lbs.  or  28.7% 
1.29  lbs.  or  23.8% 


The  curves  of  growth  in  height  show  a  similar 
trend  for  both  groups  and  their  initial  points  as  well 
as  their  final  points  are  close  together.  Both  show 
little  increase  between  October  and  February;  from 
February  through  June  and  September  there  is  an 
approximately  constant  rate  of  growth,  the  Control 
Group  gaining  more  from  February  to  June  than 
from  June  to  September,  and  the  Nutrition  gaining 
more  from  June  to  September  than  from  February 
to  June.  Rate  of  increase  in  height  is  apparently 
not  affected  to  any  extent  by  the  percentages  of 
underweight  we  are  considering.  The  percentages 
of  growth  in  height  are  as  follows : 

Gain  in  Height 


Total  Oct.-Sept. 
Oct.-Feb. 
Feb  .-June 
June-Sept 


September  Nutrition 


2.24  ins. 

0.57  in.  or  25.4% 
0.81  in.  or  36.2% 
0.86  in.    or  38.4% 


September  Control 


2.13  ins. 

0.30  in.  or  14.1% 
1.03  ins.  or  48.3% 
0.8    in.    or  37.6% 


Chart  4  contains  individual  curves  for  growth  in 
height  and  the  composite  curve  for  the  September 
Nutrition  Group.    Only  those  individuals  have  been 


132 


HEALTH  EDUCATION 


TABLE  III 
Monthly  Measueements  of  First  Grade  Pupils  1919-20 


October: 

Wt.,  lbs.. 

Ht.,  ins.  . 
November: 

Wt.,  lbs.. 

Ht.,  ins.  . 
December : 

Wt.,  lbs.. 

Ht.,  ins.  . 
January: 

Wt.,  lbs. . 

Ht.,  ins.  . 
February : 

Wt.,  lbs. . 

Ht.,  ins.  . 
March : 

Wt.,  lbs. . 

Ht.,  ins.  . 
April: 

Wt.,  lbs.. 

Ht.,  ins.  . 
May: 

Wt.,  lbs.. 

Ht.,  ias.  . 
June: 

Wt.,  lbs. . 

Ht.,  ins.  . 
October: 

Wt.,  lbs. . 

Ht.,  ins.  . 


September  Nutrition  Group 


No. of 

Cases 


44 
44 

33 
35 

36 
36 

37 
35 

31 
31 

36 
36 

38 

28 

33 
34 

36 
35 

37 
37 


Aver- 
age 


39.32 
43.35 

40.74 
43.36 

41.81 
43.71 

42.04 
43.56 

42.32 
43.84 

43.01 
44.05 

43.73 
44.35 

44.25 
44.39 

43.88 
44.67 

44.72 
45.69 


3.371 

1.703 

3.260 
1.559 

4.499 
1.730 

3.637 
1.657 

3.454 
1.755 

3.943 
1.894 

4.182 
1.798 

4.340 
1.985 

4.331 
1.918 

4.319 
2.058 


P.E. 


.3438 
.1737 

.3814 

.1777 

.5038 
.1937 

.4037 

.1888 

.4179 
.2123 

.4416 
.2121 

.4558 
.2283 

.5077 
.2302 

.4850 
.2186 

.4794 
.2284 


September  Control  Group 


No.of 

Cases 


47 
47 


44 
44 


39 
39 


43 

43 


42 
42 

41 
41 


Aver- 
age 


44.31 
43.66 


46.15 
43.84 


46.90 
43.96 


48.04 
44.59 


48.67 
45.04 

49.72 
45.82 


3.128 
1.602 


3.457 
1.367 


3.577 
1.438 


3.628 
1.659 


3.739 
1.584 

4.492 
1.755 


P.E. 


.3065 
.1569 


.3526 
.1394 


.3863 
.1553 


.3736 
.1708 


.3888 
.1647 

.4716 
.1842 


GROWTH  IN  WEIGHT  AND  HEIGHT       133 


'^C—, 


Chart  4 
Curves  op  Growth  in  Height  — 


Individual 
Composite 


134  HEALTH  EDUCATION 

included  who  had  sufficient  measurements  to  make 
comparable  curves. 

Their  significance  lies  in  the  similarity  between 
the  individual  rates  of  growth  in  height  with  but 
little  deviation  from  the  trend  of  the  composite 
curve. 

EELATIVE  GAINS  AND  VARYING  DEGREES  OF  UNDERWEIGHT 

In  order  to  throw  some  light  upon  the  variation 
in  growth  within  the  Nutrition  Group,  we  have  sub- 
divided it  into  three  sections ;  one  is  made  up  of  the 
children  8  and  97c  underweight  (Section  1),  another 
of  the  children  10-12%  underweight  (Section  2),  and 
a  third  of  the  children  13-20%  underweight  (Section 
3).  These  sections  contain  8,  20,  and  9  cases  respect- 
ively, the  first  and  third  each  comprising  approxi- 
mately 25%  of  the  entire  group.  Only  those  children 
are  included  for  whom  we  had  weighings  in  October, 
February,  and  June. 

In  Chart  5,  we  have  plotted  the  averages  for  these 
sections;  it  is  evident  that  there  is  a  close  corre- 
spondence between  Section  2  and  Section  3  both  in 
their  initial  measurements  and  in  gains  in  weight 
during  the  time  of  the  Nutrition  Class.  Starting 
at  39.3  lbs.  and  38.6  lbs.  respectively  in  October,  they 
are  41.4  and  41.6  in  February,  and  42.2  and  42.4  in 
June.  Section  2  gains  3.8  lbs.  in  the  8  months 
period;  Section  3  gains  2.9  lbs.  The  expected  gain 
for  children  of  this  age  and  height  according  to 
Wood  is  3.2;  according  to  Porter,  who  has  consid- 
ered seasonal  variation,  4.2  lbs.  Considering  Sec- 
tion 1,  we  find  the  average  weight  in  October  to  be 
nearly  5  lbs.  higher  than  that  for  the  other  Sections. 


GROWTH  IN  WEIGHT  AND  HEIGHT       135 


.WOOD 


42 


Chart  5 
Gain  in  Weight  of  Sections  in  First  Grade  Nutrition  Class. 


136 


HEALTH  EDUCATION 


The  curve  of  growth  also  shows  a  more  rapid  rise 
and  a  total  gain  of  5.0  lbs,  or  more  than  the  expected 
gain. 

The  averages  of  the  Control  Group  for  the  same 
months  are  much  like  those  of  Section  1. 


Average  Weight  in  Pounds 

October 

February 

June 

Total  Gain 

Control  Group 

Section  1 

44.3 
43.8 

46.9 
47.2 

48.6 
48.8 

4.3 
6.0 

These  results  suggest  that  a  percentage  of  8  or 
9%  underweight  as  determined  by  present  standards 
does  not  materially  affect  the  normal  growth  of  a 
child  in  weight;  a  percentage  underweight  of  10  or 
more  involves  less  absolute  gain  and  less  than  the 
expected  normal  gain.* 

Further  illustration  of  this  point  can  be  found  in 
Chart  6.  Individual  curves  of  growth  in  weight  by 
weekly  weighings  have  been  plotted  for  the  five 
children  in  the  Nutrition  Group  who  were  the  least 
underweight  and  for  the  five  most  underweight. 
Those  in  the  first  group  were  all  8%,  the  second 
ranged  from  15-20%  underweight.  Composite 
curves  from  the  averages  have  also  been  plotted  for 
each  of  these  divisions. 

The  8%  underweights  group  themselves  closely 
together  and  follow  the  same  trend.  The  initial 
measures  of  the  individual  curves  lie  between  44  and 

•  Benedict,  F.  G.,  Miles,  W.  R.,  Roth,  P.,  and  Smith,  H.  M.  Pub- 
lication No.  280,  Carnegie  Institution  of  Washington. — The  percent- 
age underweight  of  fasting  men  related  to  the  lowering  of  basal 
metabolism  is  noted. 


GROWTH  IN  WEIGHT  AND  HEIGHT       137 


TOUNSS 
St 


Chart  6 

September  Nutrition  Group 

Gain  in  Weight  According  to  Weekly  Weighings. 


138  HEALTH  EDUCATION 

48  lbs.,  the  final  measures  between  48.4  and  53  lbs., 
the  ranges  for  both  being  4  and  4.6  lbs.  respectively. 
The  average  gain  shown  in  the  composite  curve  is 
4.9  lbs.  in  comparison  with  3.2  lbs.,  the  expected  gain 
according  to  tables  of  Wood.* 

The  gain  of  those  most  underweight  is  not  so 
consistent;  this  would  be  expected  from  the  wider 
range  of  underweightness.  This  group  ranges  in 
initial  measurement  from  36.1  to  41.4  lbs.,  the  varia- 
tion being  5.3  lbs.;  in  final  measurement  it  ranges 
from  38.2  to  47.7  lbs.,  the  variation  being  9.5  lbs. 
The  average  gain  shown  in  the  composite  curve  is 
3.5  lbs.,  or  1.5  lbs.  less  than  the  least  underweight 
division. 

Three  individual  curves  are  closely  allied,  varia- 
tions being  limited  to  approximately  1  lb.  Of  the 
remaining  curves,  one  is  for  an  individual  17% 
underweight,  whose  curve  shows  many  fluctuations 
and  w^hose  gain  in  weight  for  the  whole  year  is  only 
2.1  lbs.  The  other  curve  is  for  the  individual  who 
is  the  most  underweight  of  the  whole  September 
Group  and  who  shows  a  larger  gain  than  anyone  else 
in  the  entire  group. 

VARIATIONS   IN    TYPE 

The  following  cases  illustrate  variations  in  type 
of  undernourished  child: 

J.  20%  underweight  in  October,  9%  underweight  a 
year  later. 

In  General  Intelligence  bright  by  the  two  Scales 
and  Performance  Tests. 

In  Highest  Eank  by  Teacher's  Rating. 

•  In  computing  this  expected  gain  we  have  referred  in  Wood's  table 
to  the  height  und  age  of  the  Nutrition  Group. 


GROWTH  IN  WEIGHT  AND   HEIGHT       139 

Motor  Control. — In  precision  of  movement  and 
coordination  not  involving  great  expenditure  of  mus- 
cular energy,  very  good. 

In  control  of  involuntary  movements  and  in 
fatigue  index  shown  by  decrease  of  output  in  contin- 
uous movements,  he  is  considerably  below  the  aver- 
age of  the  group.  There  are  evidences  of  emotional 
instability  both  from  the  objective  evaluation  of 
Questions  and  Dark  Room  Scores  and  from  the  types 
of  responses. 

He  has  various  fears :  of  the  dark,  of  loud  noises, 
of  crossing  a  bridge  over  water,  of  trying  to  swim, 
is  ill  from  riding  in  a  subway  or  from  sight  of  blood, 
and  does  not  stand  pain  quietly.  He  has  no  tremors 
or  twitches;  does  not  stutter.  It  v/ould  seem  from 
the  picture  a  case  of  bad  adjustment  habits  to  be 
overcome  primarily  by  an  analysis  of  these  and  a 
reconstruction  from  the  viewpoint  of  conscious  con- 
trol either  on  the  part  of  child  or  parent  in  the  for- 
mation of  new  habits.  This  involves  a  motivation 
which  in  this  case  seems  to  have  been  secured  by 
the  social  contact  with  the  mother  which  gave  her 
an  appreciation  of  the  needs  of  her  child,  whom  she 
puts  above  other  interests.  Also  the  child  himself 
was  clever  enough  and  sensitive  enough  in  his  re- 
sponses to  make  new  adaptations. 
B,  17%  underweight  in  October,  16%  underweight 
a  year  later. 

In  General  Intelligence  he  is  in  the  low  normal 
grouping  and  is  rated  medium  by  his  teacher.  In 
Performance  Tests  he  is  quick  in  reaction  time  but 
only  fairly  accurate.  In  Motor  Control  he  is  not  up 
to  the  average  of  the  group  either  in  rate  of  simple 


140  HEALTH  EDUCATION 

discriminative  movements  or  in  control  of  invol- 
untary movements.  He  shows  little  fatigue  in  mus- 
cular expenditure,  but  his  early  efforts  are  so  far 
below  the  average  there  is  not  a  comparable  output, 
though  a  low  threshold  of  fatigue  is  indicated.  His 
ability  to  profit  by  experience  is  fair,  and  the  time 
and  accuracy  of  association  responses  are  about  the 
average  of  the  group.  He  shows  few  signs  of  emo- 
tional instability. 

The  environment  seems  to  induce  faulty  habits  of 
living  which  make  for  a  low  state  of  physical  well- 
being  that  has  probably  been  chronic  for  years. 
Other  children  in  family  are  reported  as  much  under- 
weight as  he. 

In  Chart  7  we  have  plotted  the  curves  of  growth 
in  weight  for  those  cases  that  seem  to  be  chronic 
underweights,  showing  but  little  actual  gain. 

FAMILY   CHARACTERISTICS 

In  order  to  obtain  some  information  concerning 
the  relationship  between  the  percentage  underweight 
of  the  child  and  of  his  parents,  cards  were  sent  to 
the  various  homes  asking  that  the  weights  and 
heights  of  the  members  of  the  family  be  recorded. 
Wherever  possible  these  were  checked  up  by  meas- 
urements made  in  the  school  clinic.  In  this  way 
accurate  averages  have  been  obtained  for  23  of  the 
mothers,  but  the  fathers'  averages  are  based  for  the 
most  part  on  information  given  by  them. 

The  average  age  for  the  mothers  is  34.9  years, 
with  a  range  from  26  to  45  years;  for  the  fathers, 
39.1  years,  with  a  range  from  28  to  56  years. 


GROWTH  IN  WEIGHT  AND  HEIGHT       141 


tPDUNSS 

4? 


H 


Chart  7 


Curves  op  Growth  in  Weight  from  September  to  June  op  Se- 
lected Individuals  Showing  only  Slight  Increase. 


142 


HEALTH  EDUCATION 


No.  of  Cases 

Average 

a 

Mothers'  weight 

Mothers'  height 

34 
31 
26 
21 

138.11  lbs. 

59 .  74  ins. 
149.29  lbs. 

61.60  ins. 

22.715 
3.523 

Fathers'  weight 

Fathers'  height 

19.149 

2.886 

.  The  above  averages  have  been  compared  with  the 
norms  of  the  Metropolitan  Life  Insurance  Company 
of  weight  for  a  given  age  and  height.  Accordingly 
the  mothers  are  5%  overweight  and  the  fathers  12% 
overweight.  We  note  that  the  parents  are  low  in 
stature  compared  with  the  average  for  adults. 

A  correlation  of  .126  has  been  obtained  between 
the  percentage  underweight  of  the  child  at  his  first 
weighing  and  the  weight  of  the  mother.  Although 
not  significant  there  is  a  slight  tendency  in  this  group 
for  the  most  underweight  children  to  have  the 
heaviest  mothers. 

Fifth  Grade  Group 

The  boys  of  the  fifth  grade  Nutrition  Class  formed 
in  September,  1918,  were  also  measured  monthly 
from  September,  1919,  to  June,  1920,  and  again  in 
September,  1920.  Their  Control  Group  was  meas- 
ured in  February  and  in  June,  the  October  measures 
being  omitted  through  error  in  the  organization  of 
the  program. 


DISTRIBUTION  OF  PERCENTAGES  OVER  AND  UNDERWEIGHT 

Chart  8  represents  the  distribution  of  the  percent- 
ages over  and  underweight  for  the  entire  fifth  grade 


GROWTH  IN  WEIGHT  AND  HEIGHT       143 


Eh 


o 


pR 


o 

CM 


« 


^    o 


00      K      S  .ti 


144 


HEALTH  EDUCATION 


1 
1 
1 

1 

T" 

r* 

u 

-- 

1 
1 
1 
1 

cJ 


00 


lo 


cvJ 


m 
U 


nO 


rO 


o 
a 
O 

2; 

o 

E 

P 

;^ 

a 

Q 
< 

a 
O 

X 
E-i 


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03 
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^^ 


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to 


GROWTH   IN  WEIGHT  AND   HEIGHT       145 

entrants  in  September,  1918.  Of  223  individuals  in 
the  grade,  39,  ranging  from  7-207o  underweight, 
formed  the  fifth  grade  Nutrition  Group  and  38  in- 
dividuals, ranging  from  3%  over  to  37o  under  formed 
the  Control.  The  Nutrition  Group  averaged  9.69% 
±2.873,  the  Control,  0.6327^  ±1.952  underweight. 

Considering  the  entire  grade,  we  find  22  individ- 
uals are  of  normal  weight  for  height,  and  53  or  26.3% 
are  7%  or  more  underweight;  31  or  15.4%  are  7% 
or  more  overweight ;  2  or  1.1%  are  over  15%  under- 
weight, 3  or  1.7%  are  over  15%  overweight,  one 
reaching  52%  overweight. 

Chart  9  shows  the  distribution  of  the  fifth  grade 
Nutrition  Group  when  it  was  originally  selected  and 
of  the  same  group  in  September,  1919.  The  chrono- 
logical age  of  this  group  ranged  from  9.7  to  14.4 
years  with  an  average  of  11.2  years.  The  average 
percentage  underweight  in  September,  1918,  had 
been  reduced  from  9.69%  ±2.873  to  7.73%  ±4.146  in 
September,  1919;  the  range  which  had  been  7-20% 
under  became  1%  over  to  16%  under.  The  Probable 
Error  of  Difference  between  the  percentages  is 
0.5583,  the  actual  difference  being  3.510  times  this 
Probable  Error,  which  shows  significant  gains. 

In  1918  and  again  in  1919  there  were  8  individuals 
12%  or  more  underweight.  In  spite  of  this  simi- 
larity in  the  high  percentages  underweight,  we  find 
the  low  and  medium  percentages  grouping  them- 
selves more  closely  around  the  normal  point;  while 
in  1918  no  children  w^ere  less  than  1%  underweight, 
in  1919  we  find  14  who  are  less  than  7%,  4  of  whom 
are  within  the  Control  Group  limits. 


146 


HEALTH  EDUCATION 


COMPARATIVE  GAINS  AND  SEASONAL  VARIATION 

Table  IV  shows  the  variations  in  the  percentages 
underweight  throughout  the  two-year  period  which 
are  plotted  in  Chart  10.  The  decrease  in  percentage 
from  October  to  February  is  again  noted.  It  is 
especially  significant  that  this  group  makes  a  grad- 
ual but  consistent  reduction,  bringing  itself  accord- 
ing to  group  average  to  a  noimal  standard  by  Oc- 
tober, 1920. 

In  Chart  11  we  have  plotted  the  growth  in  weight 
and  height  for  the  fifth  grade  Nutrition  and  Control 
Groups  together  with  the  Porter  and  Wood  norms. 
Averages  are  taken  from  Table  V. 

The  weight  curves  for  these  groups  are  much  alike, 
the  gains  in  weight  from  October,  1918,  to  June, 
1920,  being  12.64  lbs.  for  the  Nutrition  Group  and 
12.11  lbs.  for  the  Control.  It  is  interesting  to  note 
the  fact  that  the  Control  is  approximately  1.3  inches 
shorter  than  the  Nutrition  Group. 

The  average  gain  in  weight  of  our  Nutrition  Group 
slightly  exceeds  the  norms  of  "Wood  and  Porter, 
although  in  actual  weight  the  latter  norms  are  con- 
siderably higher  than  ours. 


Gain  in  Pounds 


1918-1919 

1919-1920 

1918-1920 

Nutrition 

8.03 
7.00 
5.50 

8.37 
7.00 
8.00 

16.4 

Wood 

14.0 

Porter 

13.5 

GROWTH   IN   WEIGHT  AND  HEIGHT       147 


23 


1= 

O 

O 

o 

Eh 

)^^ 
o 
U 

o 

< 

o 


0 

a 


I 


148 


HEALTH  EDUCATION 


cct       Ht       rn       sr»      mt      mi       oct       mb       to     )«n      <«■       •»      on' 


Chart  11 

CuBVES  OF  Growth  in  Height  and  Weight,  Fifth  Grade  Nu- 
trition AND  Control  Groups 


GROWTH  IN  WEIGHT  AND  HEIGHT       149 


TABLE  IV 

Percentage  Underweight 
Fifth  Grade 


Nutrition 

Control 

No. 

of 

Cases 

Average 

% 
Under- 
weight 

a 

No. 

of 

Cases 

Average 

% 
Under- 
weight 

a 

October,  1918 

November,  1918..  . 
June,  1919 

October,  1919 

December,  1919 .  .  . 
February,  1920.... 

April,  1920 

June,  1920 

September,  1920... 

39 
41 
38 

37 
38 
36 
34 
34 
31 

9.69 
7.02 
6.76 

7.729 
5.144 
5.525 
4.176 
6.264 
6.419 

2.873 
3.412 
4.366 

4.146 
4.584 
5.296 
4.749 
5.002 
5.296 

38 
25 

27 

25 
25 

0.632 
+0.72 
1.11 

+0.32 
+0.60 

1.952 
3.954 
3.457 

4.805 
4.808 

150 


HEALTH  EDUCATION 


TABLE  V 
Monthly  Measurements  of  Fifth  Grade  Pupils,  1918-20 


Nutrition  Group 

Control  Group 

No. 
of 

Cases 

Aver- 
age 

<7 

No. 

of 

Cases 

Aver- 
age 

<r 

Oct., 

1918— Weight,  lbs.  . 

39 

64.82 

8.140 

38 

66.54 

8.307 

Height,  in .  .  . 

39 

53.72 

2.721 

38 

52.47 

2.678 

Nov., 

1918— Weight,  lbs.. 

41 

66.74 

8.745 

Height,  in .  .  . 

41 

53.70 

2.693 

Dec, 

1918— Weight,  lbs.. 

38 

67.89 

9.190 

25 

66.20 

7.574 

Height,  in.  .  . 

25 

52.02 

2.527 

Feb., 

1919— Weight,  lbs.. 
Height,  in.  . . 

42 

68.82 

9.890 

April, 

1919— Weight,  lbs.  . 
Height,  in.  .  . 

42 

69.23 

9.126 

June, 

1919— Weight,  lbs.  . 

40 

69.11 

9.558 

27 

68.17 

8.303 

Height,  in .  .  . 

38 

54.50 

2.905 

27 

53.07 

2.568 

Oct., 

1919— Weight,  lbs .  . 

37 

71.16 

10.506 

Height,  in .  .  . 

37 

55.36 

3.193 

Nov., 

1919— Weight,  lbs.  . 
Height,  in .  . . 

36 

72.19 

10.699 

Dec, 

1919— Weight,  lbs.  . 

38 

74.70 

12.069 

Height,  in.  .  . 

35 

56.00 

3.324 

Jan., 

1920— Weight,  lbs .  . 

38 

74.17 

11.330 

Height,  in .  .  . 

38 

55.69 

3.086 

Feb., 

1920— Weight,  lbs .  . 

37 

73.96 

9.664 

26 

76.15 

9.373 

Height,  in .  .  . 

37 

55.53 

2.905 

26 

55.02 

2.635 

March 

1920— Weight,  lbs .  . 

36 

74.87 

11.868 

Height,  in .  .  . 

36 

56.01 

3.164 

April, 

1920— Weight,  lbs.  . 

35 

74.85 

10.431 

Height,  in .  .  . 

35 

55.91 

2.800 

May, 

1920— Weight,  lbs .  . 

35 

77.89 

13.325 

Height,  in .  .  . 

36 

56.44 

3.322 

June, 

1920— Weight,  lbs... 

34 

77.46 

12.881 

25 

78.65 

9.861 

Height,  in .  .  . 

34 

56.81 

3.478 

25 

55.79 

2.677 

Oct., 

1920— Weight,  lbs... 

30 

78.30 

10.574 

Height,  in.  .  . 

30 

75.25 

3.033 

GROWTH   IN  WEIGHT  AND   HEIGHT       151 


The  percentages  whicli  follow  show  gains  made 
in  periods  of  four  months  by  the  Nutrition  Group. 

Fifth  Grade  Nutrition  Group 

Gain  in  Weight 


No. 

No. 

of 

1918 

of 

1919 

Cases 

Cases 

Oct. 

-Oct. 

8 

03  lbs. 

or 

100% 

8.37  lbs. 

or 

100% 

Oct. 

-Feb. 

38 

4 

64  lbs. 

or 

57.8% 

36 

3.58  lbs. 

or 

42.8% 

Feb. 

-June 

38 

1 

58  lbs. 

or 

19.7% 

33 

2.3    lbs. 

or 

27.5% 

Jime-Oct. 

36 

1 

81  lbs. 

or 

22.5% 

29 

2.49  lbs. 

or 

29.7% 

Gain  in  Height 


Oct  .-Oct. 

2 

08  ins. 

or 

100% 

2 

12  in. 

or 

100% 

Oct  .-Feb. 
Feb  .-June 

} 

1 

35  ins. 

or 

64.9% 

0 
0 

32  in. 
97  in. 

or 
or 

15.1% 

45.8% 

June-Oct. 

0 

73  in. 

or 

35.1% 

0 

83  in. 

or 

39.1% 

Here  again  the  greater  increase  in  weight  can  be 
noted  from  October  to  February.  From  February 
to  June  we  again  have  a  reduction  in  rate  of  growth, 
but  in  1918-19  it  is  a  very  pronounced  one,  due  in 
a  measure  to  the  fact  that  13  children  of  the  group 
had  tonsil  operations  from  March  to  June  and  lost 
an  average  of  3  lbs.  in  weight. 

EELATIVE  GAINS  AND  VAKYING  DEGREES  OP  UNDERWEIGHT 

Relative  gains  made  by  groups  differing  in  degree 
of  percentage  underweight  are  shoAvn  in  Table  VI. 

The  two  sections  are  formed  by  taking  from  the 
entire  grouping  the  22  cases  who  gained  enough 


152 


HEALTH  EDUCATION 


TABLE  VI 
Percentage  Underweight 
Fifth  Grade  Nutrition  Class 


No.  of  Cases 

Average 

% 
Underweight 

<r 

October,  1918 

Section    1 

2 

November,  1918: 

Section    1 

2 

June,  1919: 
Section    1 

17 

22 

18 
23 

21 

17 

19 
19 

19 

18 

19 
19 

15 
14 

11.47 
8.32 

9.94 
4.74 

8.33 

4.82 

9.74 

5.84 

6.58 
2.11 

8.00 
4.42 

7.73 
5.93 

3.311 
1.316 

2.967 
1.386 

4.275 

2 

3.638 

October,  1919: 

Section    1 

4.170 

2 

3.137 

February,  1920: 

Section    1 

5.038 

2 

3.650 

June,  1920: 

Section    1 

5.026 

2 

3.775 

September,  1920: 

Section    1 

4.828 

2 

5.402 

GROWTH  IN  WEIGHT  AND  HEIGHT       153 


Gain  in  Weight 
1918-1919 


No. 

No. 

of 

Section  1 

of 

Section  2 

Cases 

Cases 

Oct.-Oct. 

6.83  lbs. 

or  100% 

9.01  lbs. 

or  100% 

Oct. -Feb. 

17 

3.5    lbs. 

or  51 

2% 

21 

5.57  lbs. 

or  61.8% 

Feb  .-June 

20 

1 .  78  lbs. 

or  26 

1% 

18 

1.36  lbs. 

or  15.1% 

June-Oct. 

18 

1.55  lbs. 

or  22 

7% 

18 

2.08  lbs. 

or  23.1% 

1919-1920 


Oct.-Oct 

Oct  .-Feb. 
Feb  .-June 
June-Oct. 


18 
18 
15 


8.16  lbs.  or  100% 
3.26  lbs.  or  39.9% 
2.16  lbs.  or  26.5% 
2.74  lbs.  or  33.6% 


18 
15 
14 


8.59  lbs.  or  100% 
3.89  lbs.  or  45.3% 
2.47  lbs.  or  28.7% 
2.23  lbs.  or  26% 


in  the  period  elapsing  between  the  original  weigh- 
ing in  October,  1918,  and  the  forming  of  the  class 
in  November  to  bring  them  to  a  normal  standard. 
These  are  called  Section  2.  While  the  numbers  vary 
for  these  two  groups  because  of  additions  to  the 
sections  throughout  this  period,  there  was  no  inter- 
change from  one  section  to  another.  It  is  evident 
that  at  least  half  of  this  group  were  not  under- 
nourished and  that  their  rate  of  growth  corre- 
sponds with  the  normal  expectations.  It  is  gratify- 
ing to  note  the  gains  made  by  Section  1  during  the 
two  years.  They  increased  from  11.47%  underweight 
in  October,  1918,  to  7.73%  underweight  in  Septem- 
ber, 1920. 


154 


HEALTH  EDUCATION 


The  percentages  of  gain  made  by  the  two  sec- 
tions are  of  interest  because  of  the  similarity  in  sea- 
sonal growth  Avhich  is  shown.  The  largest  increase 
in  weight  occurs  between  October  and  February. 
The  increase  in  weight  for  both  sections  compares 
favorably  with  Wood's  and  Porter's  norms. 

Gain  in  Weight 


1918-1919 

1919-1920 

1918-1920 

Section  1 

Section  2 

Wood 

Porter 

6.83  lbs. 
9.01  lbs. 
7.00  lbs. 
5.50  lbs. 

8.16  lbs. 
8.59  lbs. 
7.00  lbs. 
8.00  lbs. 

14.99  lbs. 
17.6    lbs. 
14.00  lbs. 
13.50  lbs. 

It  is  of  interest  that  the  most  underweight  section 
gains  slightly  more  than  the  normal  groups  of  Porter 
and  Wood  for  the  two-year  period. 


Interpretations 

While  a  sampling  of  207  Hebrew  boys,  791/2%  of 
whom  are  of  Austrian  or  of  Russian  parentage  with 
homes  in  New  York's  crowded  East  side,  may  not 
be  considered  representative  of  children  at  large 
between  the  ages  of  five  and  a  half  and  seven  and 
a  half  years,  we  can  compare  the  two  first  grade 
groups  similarly  selected  for  study,  consider  the 
variations  within  the  groups,  and  summarize  cer- 
tain findings  as  to  growth  in  height  and  weight.  It 
is  significant  that  these  findings  are  corroborated 
by  the  results  from  the  measurements  of  the  older 
boys  throughout  a  two  year  period. 


GROWTH   IN   WEIGHT   AND   HEIGHT       155 

(1)  A  comparison  of  the  numbers  underweight 
in  various  school  populations  is  not  valid,  aside  from 
other  conditioning  factors,  unless  the  measurements 
are  taken  at  the  same  period  of  the  year.  There  is 
a  marked  seasonal  variation  in  gain  in  weight;  the 
greatest  increase  both  absolutely  and  relatively 
occurs  between  September  and  February.  There  is 
a  more  constant  rate  of  increase  in  height  with  slight 
acceleration  from  Februai^  to  September,  inverse 
to  the  increase  in  weight.  These  two  factors  cause 
an  appreciable  difference  in  height-weight  indices 
throughout  a  year.  This  was  found  true  not  only 
for  the  first  grade  children  but  also  for  those  of  the 
fifth  and  sixth  grades;  for  the  Control  or  approxi- 
mately normal  groups  as  well  as  for  the  undernour- 
ished. While  25%  of  the  February  entrants  to  the 
first  grade  were  found  to  be  7%  or  more  under- 
weight, 50.7%  of  the  number  entering  in  September 
were  7%  or  more  underweight. 

(2)  The  definition  of  malnutrition  or  undernour- 
ishment as  a  function  of  the  height-tv eight-age  rela- 
tionships with  the  acceptance  of  a  7%  standard  is 
not  statistically  justified.  The  children  of  the  First 
Grade  group  who  are  7,  8  and  9%  underweight  at 
the  end  of  the  season  of  minimal  increase  in  weight 
behave  as  the  Control  Group  in  rate  of  growth  and 
compare  favorably  with  the  growth  records  estab- 
lished as  normal  for  a  large  group  of  children  at 
large.  Those  who  are  10%  or  more  underweight  are 
more  erratic.  Two  types  are  specifically  noted :  the 
markedly  retarded  case  who  gains  and  loses  irregu- 
larly and  remains  practically  upon  a  level  for  a  long 
period  of  time ;  the  rapid  gainer  who  surpasses  the 


156  HEALTH  EDUCATION 

normal  rate  but  sliows  more  fluctuations  in  his  prog- 
ress and  finally  attains  a  normal  level.  For  him 
environmental  control  works  wonders.  The  former 
offers  a  distinct  problem  in  the  field  of  malnutrition. 
(3)  The  static  standards,  as  7 To  for  all  ages,  do 
not  seem  justified.  From  this  same  school  only  23% 
of  223  fifth  grade  children  entering  in  September, 
1918,  were  found  underweight  according  to  this 
standard;  50.7%  of  126  first  grade  children  entering 
in  September,  1919,  were  found  underweight.  In 
February,  1918,  there  was  not  a  marked  difference 
in  the  percentage  underweight  of  the  various  grades. 
The  difference  in  percentage  of  gain  in  excess  of 
normal  was  made  more  striking.  The  first  grade 
children  gained  37.5%  more  than  the  normal  gain 
for  the  period  of  observation,  which  considerably 
exceeded  the  gain  made  by  all  other  classes  except 
the  Terman  group.  While  the  factor  of  greater 
home  control  and  parental  cooperation  largely  ac- 
counts for  this  record,  it  is  probable  too  that  it  in- 
dicates a  better  nutritional  status  for  the  first  grade. 

Stimmary 

The  experiment  of  1919-1920  proved  reassuring 
in  many  respects.  That  the  procedure  developed  for 
first  grade  children  yielded  better  results  than  that 
previously  used  by  us  is  shown  by  the  number  of 
individuals  ''making  normal"  during  the  period  of 
instruction  and  by  the  definite  reduction  effected  in 
the  average  percentage  of  underweight.  Of  the  48 
children   enrolled   in   September,   20   or   45%   had 


GROWTH    IN    WEIGHT   AND    HEIGHT      157 

reached  normal  weight  for  height  in  June  and  the 
average  underweight  of  the  class  had  been  reduced 
from  11.56  to  6.54%.  It  will  be  evident  that  the 
inferior  record  of  the  smaller  group  enrolled  in 
February,  2  children  out  of  10  (20%)  making  nor- 
mal, and  the  average  of  underweight  reduced  only 
from  11.46  to  11%,  is  perfectly  in  keeping  with  the 
general  facts  of  our  experience,  that  the  factor  of 
seasonal  variation  renders  results  in  weight  increase 
relatively  slight  during  the  second  term  of  school. 

That  the  enlistment  of  effective  home  cooperation 
in  conjunction  with  the  earlier  age  period  of  the  chil- 
dren furnishes  an  adequate  explanation  for  the  rel- 
ative efficiency  of  this  third  program  of  experiment 
will  be  obvious.  The  program  of  instruction  was  a 
slender  one  but  was  calculated  to  enlist  the  child's 
cooperation  successfully.  We  can  appreciate  that 
additional  school  facilities  for  concrete  experiences 
especially  in  food  taking,  selection,  and  preparation, 
and  for  additional  rest  and  fresh  air,  might  have 
considerably  augmented  the  results  obtained. 

The  data  collected  on  physical  histories  and  the 
more  careful  physical  examinations  made  of  the  chil- 
dren in  this  third  experiment  have  resulted  in  a  far 
clearer  appreciation  of  the  causal  factors  and  of  the 
conditions  governing  individual  response  than  had 
been  ours  previously,  while  the  detailed  study  of 
growth  in  height  and  weight  has  been  clarifying  to 
the  entire  experience.  At  the  same  time  the  need  of 
a  very  considerable  amount  of  research  in  respect 
to  standards  of  growth,  and  in  respect  to  causal  fac- 
tors, has  been  made  apparent.    For  this  reason  we 


158  HEALTH  EDUCATION 

submit,  in  a  subsequent  chapter,  some  general  inter- 
pretations of  our  experience,  and  recommendations 
for  such  further  experiment  as  seems  to  us  most 
obviously  needed,  to  place  botli  corrective  work  for 
malnutrition  and  general  procedures  in  health  edu- 
cation on  a  more  secure  scientific  basis. 


CHAPTEE  VII 

MENTAL  MEASUREMENTS  OF  FIRST  GRADE 
CHILDREN 

Group  Selection 

The  formation  of  a  Nutrition  Class  and  a  Control 
Group  from  the  first  grade  entrants  in  September, 
1919,  was  determined  solely  by  the  respective  per- 
centages underweight.  These  two  groups  were  not 
made  equivalent  as  to  physical  status,  economic 
status,  racial  or  stock  differences,  nor  was  the  dis- 
tribution of  percentages  underweight  similar  with 
respect  to  variations  from  the  central  tendencies. 
The  set-up  was  arranged  for  a  comparative  study 
of  growth  in  weight  and  height  of  these  groups  and 
did  not  permit  the  control  of  such  factors  as  given 
above.  This  makes  unsatisfactory  experimental 
conditions  for  direct  comparison  of  mental  traits. 

All  the  children  in  these  classes  were  boys  and 
95%  of  those  in  the  Nutrition  Class  were  Hebrews. 
The  racial  distribution  of  the  two  groups  was  ap- 
proximately the  same.  The  Nutrition  Group  varied 
from  8  to  20%  underweight  as  compared  with  norms, 
while  the  Control  Group  ranged  from  7%  under- 
weight to  5%  overweight.  Physical  examinations 
were  made  of  the  Nutrition  Group.  ( See  pp.  109-117. ) 
No  physical  examinations  were  made  of  the  Control 
Group.  The  Nutrition  Class  was  segregated  into  one 
class-room  and  came  into  direct  contact  with  various 

159 


160  HEALTH  EDUCATION 

members  of  the  staff  each  week.  They  were  also 
given  milk  each  day.  This  makes  for  a  very  dif- 
ferent attitude  as  compared  with  that  of  the  Control 
Group,  who  were  separated  in  two  class-rooms  and 
after  the  first  weighing  and  measuring  had  no  other 
contacts  preceding  the  mental  examinations.  These 
conditions  seem  to  offer  a  better  opportunity  for  an 
intensive  study  of  a  small  group  of  undernourished 
children  than  for  comparative  records. 

It  was  decided  to  evaluate  the  Nutrition  Class  and 
the  Control  Group  as  to  general  intelligence  rating, 
and  to  compare  them  in  a  few  specific  performances 
including  a  simple  learning  process,  then  to  make 
a  more  intensive  study  of  the  types  of  responses 
made  by  the  undernourished  boys  under  varying 
forms  of  control.  These  examinations  were  given 
during  January  and  February  after  the  children  had 
become  accustomed  to  the  routine  class  procedure. 

A  series  of  tests  was  given  to  the  children  of  the 
Nutrition  and  Control  Groups  in  the  Nature  Study 
laboratory  of  the  school,  one  section  of  which  was 
screened  off  so  that  the  distraction  from  the  rabbits 
and  chickens  seemed  negligible.  Each  child  was 
taken  individually  for  an  examination  which  lasted 
approximately  half  an  hour  between  the  hours  of 
nine  and  eleven  in  the  morning.  This  series  included 
the  following  tests:  Card  Sorting,  Cancellation, 
Action-Agent,  and  Cylinders. 

After  this  series  was  completed  the  children  in 
the  Nutrition  Group  were  brought  to  our  laboratory 
in  the  afternoon  in  groups  of  four  and  five,  and 
were  given  individually  the  f  oUomng  series  of  tests : 
Tapping  (Single  Plate),  Tapping  (Double  Plate), 


MENTAL  MEASUREMENTS  161 

Target,  Steadiness,  Walking  Board,  Substitution, 
and  Ship  Test.  The  scores  for  the  Haggerty  Mental 
Examination,  the  Intelligence  Quotients  by  the 
Stanford  Revision  of  the  Binet-Simon  Scale,  and  the 
teacher's  ratings  were  obtained  from  the  school 
authorities.  The  Haggerty  tests  were  given  under 
the  auspices  of  the  Bureau  of  Reference  and  Re- 
search of  the  New  York  City  school  system,  under 
the  direction  of  Mr.  J.  L.  Stenquist.  The  Stanford 
Revision  examinations  were  given  by  Miss  Elisabeth 
Irwin,  the  school  psychologist,  and  the  teacher's 
marks  were  obtained  from  Miss  Louise  Specht,  as- 
sistant principal  of  the  school.  The  tests  given  in 
the  laboratory  were  selected  for  the  purpose  of  meas- 
uring the  rapidity  and  accuracy  of  responses  in  vary- 
ing performances  with  special  reference  to  fatigue 
and  practice  effects. 

Apparatus  and  Procedure 

Slight  variations  from  the  standard  test  proce- 
dures were  made  where  it  seemed  necessary  for  a 
complete  understanding  of  the  requirements  by  six- 
year  old  subjects. 

Card  Sorting. — The  method  followed  was  that 
given  in  the  Monograph  by  Woolley  and  Fischer, 
"Mental  and  Physical  Measurements  of  Working 
Children,"  page  100,  with  the  exception  that  two 
sets  of  24  cards  were  used  instead  of  one  set  of  48 
cards.  The  time  for  each  of  the  two  trials  was 
recorded. 

Cancellation. — The  capital  A  blank  was  used  and 
the  method  of  Woolley  and  Fischer  (page  108)  fol- 
lowed, except  that  when  the  examiner  showed  the 


162  HEALTH  EDUCATION 

practice  sheet,  the  subject  was  instructed  to  ''mark 
out  the  next  two  A's,"  the  examiner  helping  the 
child  to  find  them  and  correcting  any  errors  at  once. 

Action-Agent  Association  Test. — The  instructions 
in  the  Monograph  ''Association  Tests/'  by  Wood- 
worth  and  Wells  (page  63)  were  followed.  Only  nine 
of  the  words  listed  by  them  were  used  in  our  series. 
The  comprehension  of  English  by  these  young  chil- 
dren, in  whose  homes  a  foreign  language  is  usually 
spoken,  was  not  good  enough  to  include  all  the 
words  of  that  list.  The  words  used  were:  gallops, 
bites,  cuts,  rings,  scratches,  growls,  cries,  stings, 
flies,  ticks,  shines,  blows,  rolls,  creeps,  burns.  This 
list  of  words  has  been  used  with  a  number  of  chil- 
dren of  the  same  age,  which  oifers  an  opportunity 
for  comparison  of  results  as  to  reaction  time  and 
accuracy  of  response. 

Cylinders. — (Witmer.) — A  description  of  this  test, 
together  with  suggestions  for  its  use,  is  given  by 
Paschal  in  the  Psychological  Clinic,  April  15,  1918, 
and  by  Ide  in  the  same  Journal  for  May  15,  1918. 
Our  procedure  was  to  set  the  box  with  the  cylinders 
correctly  placed  before  the  subject  with  the  largest 
cylinders  farthest  from  him.  The  examiner  said, 
"Do  you  see  this  box  with  the  blocks  fitted  into  it? 
Each  one  has  its  own  place."  While  removing  the 
cylinders  from  the  box  the  examiner  said,  *'I  am 
going  to  put  them  in  the  center  and  I  want  you  to 
put  them  back  where  they  belong.  You  may  use  one 
hand  or  both  and  work  as  fast  as  you  can." 

The  child  was  allowed  to  work  as  long  as  he 
showed  indications  of  completing  the  test  correctly. 
If  he  did  not  succeed  at  the  end  of  five  minutes,  he 


MENTAL  MEASUREMENTS  163 

was  assisted  with  suggestions  until  all  the  cylinders 
were  correctly  placed.  The  time  for  each  of  three 
trials  was  recorded,  also  the  number  of  wrongly 
placed  cylinders  at  the  end  of  each  trial. 

Rapidity  of  Movement  of  the  Hand  in  Single  Tap- 
ping.— The  method  of  administering  the  test  was 
that  described  in  the  Monograph  by  Woolley  and 
Fischer  (page  75)  with  the  exception  that  the  tap- 
ping was  continued  for  li/o  minutes  and  readings 
of  the  dial  were  taken  for  each  half  minute  instead 
of  for  each  15  second  period.  The  index  of  fatigue 
was  calculated  by  considering  the  loss  in  the  last 
30  seconds  as  compared  with  the  first  30  seconds. 

Rapidity  of  Movement — Tapping  on  Double  Plate. 
— This  was  a  more  complex  form  of  movement  than 
the  tapping  on  the  single  plate.  The  plate  was  de- 
vised by  Professor  Knight  Dunlap  and  consists  of  a 
black,  hard  rubber  base,  6  inches  by  3  inches,  upon 
which  two  brass  plates,  3  inches  by  2i/^  inches,  were 
attached,  separated  by  a  black  bar  15/16  of  an  inch 
in  width.  To  each  brass  plate  there  was  attached  a 
binding  post,  so  that  the  taps  for  the  two  plates 
could  be  registered  separately.  The  plates,  stylus, 
and  electric  enumerator  were  wired  in  series  with 
battery,  so  that  contact  of  stylus  with  either  plate 
recorded  a  count  in  the  enumerator.  After  subject 
had  been  told  that  he  was  to  grasp  the  stylus  in  his 
right  hand  and  tap  first  upon  one  plate  then  upon 
the  other,  just  as  rapidly  as  possible,  the  procedure 
was  illustrated,  and  he  was  allowed  to  make  a  few 
taps  so  that  he  understood  what  was  expected  of 
him.  He  was  told  that  he  should  continue  tapping 
until    the    command    to    stop.      The    counter   was 


164  HEALTH  EDUCATION 

screened  from  his  view,  and  the  experimenter  sat 
facing  him.  Each  child  stood  during  this  perform- 
ance, and  by  means  of  a  wooden  platform  the  plate 
was  adjusted  according  to  the  height  of  the  child. 

When  the  command  to  begin  was  given  a  stop- 
watch was  started.  This  was  placed  upon  a  stand 
by  the  side  of  the  enumerator,  so  that  the  score  for 
30  second  periods  could  be  recorded.  We  realized 
the  difficulty  in  following  two  moving  hands  for 
making  accurate  records.  The  tapping  was  con- 
tinued for  a  minute  and  a  half,  and  we  believe  the 
control  was  sufficient  to  give  indications  of  fatigue 
effects.  At  the  onset  of  fatigue  there  was  a  tendency 
to  scrape  across  the  dividing  board  from  one  plate 
to  another,  to  strike  the  dividing  board  instead  of 
one  of  the  plates,  to  hit  several  times  on  one  side 
and  then  several  times  on  the  other,  and  to  stop  for 
rest.  If  the  stylus  was  held  too  loosely  it  sometimes 
failed  to  record.  Holding  of  the  stylus  too  tightly 
was  usually  accompanied  by  pounding.  If  the  child 
stopped  he  was  told  to  go  on.  If  he  continued  to  hit 
several  times  on  one  side  of  the  plate  he  was  told 
to  ''hit  first  one  side  then  the  other,"  and  if  the 
failure  to  register  seemed  to  be  due  to  a  loose  grasp, 
it  was  suggested  that  he  hold  the  stylus  more  tightly. 
The  rate  of  these  young  children  was  such  that  there 
was  not  a  large  probability  of  error  in  recording 
the  score  for  the  different  periods. 

The  Target  Test. — This  apparatus  and  the  pro- 
cedure for  conducting  this  test  were  described  by 
Johnson  in  the  PsycJiological  Review  for  July,  1919, 
''Practice  Effects  in  a  Target  Test.  A  Compara- 
tive Study  of  Groups  Varying  in  Intelligence."    The 


MENTAL  MEASUREMENTS  165 

procedure  was  modified  in  adaptation  to  the  age  of 
the  children,  and  only  thirty  throws  were  given  to 
each  child  in  series  of  ten  throws  each,  one  dart 
thrown  immediately  after  the  other  at  a  distance  of 
ten  feet  from  the  target. 

The  Steadiness  Test. — The  procedure  followed 
was  that  described  in  the  Monograph  by  Woolley 
and  Fischer,  ''Mental  and  Physical  Measurements 
of  Working  Children"  (page  63),  mth  the  following 
modifications:  instead  of  seating  the  child,  he  was 
standing,  and  the  adjustments  for  individual  heights 
were  made  by  means  of  a  wooden  platform  upon 
which  he  stood ;  instead  of  beginning  with  the  fourth 
hole  for  these  young  children  we  began  with  the 
first  hole,  taking  as  an  arbitrary  limit  that  hole  in 
which  not  more  than  twelve  contacts  were  made. 
Scores  were  recorded  in  terms  of  the  hole  reached 
and  the  number  of  contacts  made. 

The  Walking  Board. — This  board  was  devised  for 
the  purpose  of  getting  at  some  measure  of  general 
bodily  control,  and  consisted  of  a  piece  of  hard  wood, 
6  feet  long,  2%  inches  wide,  and  2i/^  inches  thick. 
The  upper  side  of  the  board  had  a  half  inch  rounded 
off  on  either  edge.  This  board  was  securely  fas- 
tened upon  wooden  end  supports  which  raised  it 
from  the  floor  a  distance  of  5  inches  to  the  level  of 
the  upper  side,  and  had  the  appearance  of  a  rail. 
This  rail  was  divided  into  four  equal  parts  by  means 
of  cylindrical  insets  having  a  base  li/4  inches  in 
diameter.    These  divisions  were  called  I,  II,  III,  IV. 

The  subject  was  asked  to  walk  from  one  end  to 
the  other  without  stepping  off  if  possible,  and  was 
told  that  if  he  did  step  off  to  step  back  on  again 


166  HEALTH  EDUCATION 

and  continue  to  the  other  end.  This  was  done  for 
three  times  in  succession.  Scores- were  kept  of  the 
number  of  steps  off  in  each  division  and  for  each 
trial.  In  the  tables  only  the  total  scores  for  these 
three  trials  are  given. 

Substitution. — (Woodworth  &  Wells.)  The  first 
half  of  the  Woodworth  &  Wells  blank  was  used 
with  the  instructions  given  in  Mrs.  Woolley's  study. 
Slight  changes  were  necessary  because  of  the  pres- 
ence of  the  key  at  the  top  of  the  blank  instead  of 
on  a  separate  card.  The  child  was  allowed  to  fill  in 
the  first  two  figures  with  the  examiner's  assistance. 
When  the  fifth  line  was  reached  the  key  and  the  first 
four  lines  were  covered  up  and  the  child  told  to 
''do  it  from  memory." 

The  Ship  Test. — This  test  is  described  by  Pintner 
and  Patterson  in  ''A  Scale  of  Performance  Tests," 
(page  58).  Their  method  of  giving  the  test  was  fol- 
lowed. 

Dark  Room  Experiment. — A  number  of  these  chil- 
dren gave  evidence  of  emotional  instability  and  of 
fear  of  the  dark,  so  a  form  of  getting  some  object- 
ive measure  of  reactions  to  remaining  in  a  dark 
room  was  attempted.  The  steadiness  plate,  used  in 
the  test  of  control  of  involuntary  movements,  a 
kymograph,  Jaquet  time  marker,  and  an  electric 
marker  were  wired  in  series  with  a  battery  so  that 
contact  of  a  stylus  resting  upon  subject's  hand  was 
recorded  upon  a  smoked  paper  on  a  revolving  drum. 
The  subject  was  seated  by  a  table  and  his  arm  was 
placed  upon  a  resting  board  so  that  the  entire  length 
of  the  arm  and  hand  was  in  contact  with  the  board. 
The  hand  was  allowed  to  rest  easily  with  the  fingers 


MENTAL  MEASUREMENTS  167 

extended  forward,  touching  eaeli  other.  On  the  back 
of  his  hand,  so  that  it  fell  in  the  groove  between  the 
forefinger  and  the  second  finger,  the  stylus  was 
placed.  The  steadiness  plate  was  arranged  at  the 
end  of  this  board  so  that  hole  4  in  the  upper  row, 
which  was  12/64  of  an  inch  in  diameter,  was  in  a 
vertical  plane  in  such  position  that  the  stylus,  rest- 
ing lightly  upon  the  fingers,  extended  for  a  distance 
of  approximately  a  quarter  of  an  inch  through  the 
center  of  the  hole. 

The  light  was  turned  on  in  the  dark  I'oom  while 
the  child  was  adjusted  to  this  position.  He  was  told 
to  let  his  hand  rest  there,  keeping  it  as  still  as  he 
could  so  that  the  stylus  would  not  move,  and  that 
the  light  would  be  turned  out  for  a  time.  He  was 
assured  that  this  would  not  be  for  very  long  and 
he  must  remain  as  still  as  he  could.  Then  the 
marker  was  started,  and  the  drum  and  a  stopwatch 
were  started  simultaneously.  After  15  seconds  the 
light  was  turned  out,  the  experimenter  stepped  out- 
side the  door  just  behind  her,  closing  it  so  that  the 
child  was  left  in  a  dark  room  for  45  seconds.  The 
light  was  then  turned  on  again  and  after  10  seconds 
the  drum  was  stopped.  The  number  of  contacts 
made  during  the  period  of  darkness  was  scored. 

Questionnaire. — The  questions  used  were  taken 
from  a  list,  given  to  a  number  of  children  for  obtain- 
ing information  that  might  suggest  emotional  in- 
stability, that  was  originally  developed  from  Wood- 
worth's  list  for  adults  based  upon  available  ac- 
counts of  symptoms  ante-dating  mental  breakdowns 
and  indicating  poorly  balanced  emotional  conditions. 
For  each  question  one   answer  is  assumed  to  be 


168  HEALTH  EDUCATION 

wrong.  This  assumption  is  based  upon  the  answers 
given  by  normal  individuals.  The  score  is  the  total 
number  of  wrong  answers.  A  discussion  of  these 
questions  is  given  by  Franz.*  A  report  of  the  pre- 
liminary study  on  children  was  made  in  ''Un- 
graded" for  January,  1920,  which  describes  scoring 
and  interpretation  of  data.  The  following  questions 
were  given  to  each  child  individually  and  the  social 
investigator  asked  the  mother  the  same  questions  as 
a  check  upon  the  child's  answers  in  some  cases  and 
to  secure  exact  information  in  others.  The  ques- 
tions were  asked  informally  after  the  child  had  taken 
part  in  other  experiments  and  was  at  ease.  He 
seemed  interested  in  his  past  experiences  and  his 
illustrations  often  gave  more  direct  information 
than  his  categorical  replies. 

Do  you  wake  up  frightened  in  the  middle  of  the  night  I 
Do  you  ever  walk  in  your  sleep? 
Do  you  cry  out  in  your  sleep? 

Do  you  want  a  light  in  your  room  during  the  night? 
Do  you  have  a  great  many  bad  headaches? 
Have  you  ever  fainted  away? 

Do  you  like  to  play  alone  better  than  with  children? 
Do  the  other  children  let  you  play  with  them? 
Are  you  shy  with  other  children? 
Did  you  ever  run  away  from  home? 
Did  you  ever  get  lost? 
Do  you  get  used  to  new  places  easily? 
Do  you  find  your  way  about  easily? 
Do  you  have  trouble  walking  in  the  dark? 
Are  you  afraid  of  the  dark? 

Does  it  make  you  uneasy  to  cross  a  bridge  over  a  river? 
Does  it  make  you  uneasy  to  go  into  a  tunnel  or  subway? 
Does  it  make  you  uneasy  to  have  to  cross  a  wide  street  or  open 
square? 

•  Franz,   S.    I.,  Eandbooh  of  Menial  Exammation  Methods,  The 
MacMillan  Co.,  1919,  p.  170. 


MENTAL  MEASUREMENTS 


169 


Do  you  have  a  great  fear  of  fire? 

Did  you  ever  have  the  habit  of  biting  your  finger  nails  T 
Did  you  ever  have  the  habit  of  stuttering? 

Did  you  ever  have  the  habit  of  twitching  your  face,  n«ek,  gr 
shoulders? 

Did  you  ever  have  the  habit  of  wetting  the  bed? 

Have  you  a  good  appetite? 

Are  you  usually  happy? 

Do  you  cry  easily? 

Are  you  easy  to  get  angry? 

Can  you  stand  pain  as  quietly  as  other  people  do? 

Can  you  stand  the  sight  of  blood? 

Do  you  like  out-door  games? 

Have  you  a  nickname? 

Do  you  do  well  in  school? 

Have  you  any  unusual  fears? 

Is  there  any  food  you  especially  dislike? 

Do  you  break  things  often? 

Do  you  fight  other  children? 

Do  you  tease  others? 

Teacher's  Ratings. — To  the  marks  given  by  the 
teacher  no  numerical  value  was  assigned,  but  to 
facilitate  computation  we  have  used  an  arbitrary 
numerical  value  in  place  of  the  original  alphabetic 
ranking.  The  following  values  were  assigned  to  the 
school  markings : 


School  Work 

Mark 

Numerical  Value 

Failure 

Fair 

D 
C 
B 

B  + 
A 

1 
2 

Good 

3 

Very  good 

4 

Excellent 

5 

170 


HEALTH  EDUCATION 


H 


O 


MENTAL  MEASUREMENTS 


171 


I 
I 
I 
I 

LJ 


I 


I 
I 
I 
I 


o 


CI     I 
o  ^ 

■-I3    o 


« 
O 

o 

!« 

H 

o 
o 
< 

O 

O 

?! 
P 


172 


HEALTH  EDUCATION 


TABLE  I 

NtTTRiTioN  Group 
First  Grade 


Stanford 

Revision 

I.Q. 

Haggerty 

Teacher's 

Question- 

Score 

Rating 

naire 

A.  B 

100 

35 

5 

7 

M.B 

87 

N.C 

87 

33 

3 

11 

B.  D 

95 

30 

2 

9 

S.  Fa 

126 

71 

5 

3 

J.  Fa 

3 

4 

S.  Fi 

100 

34 

10 

J.  Fr 

102 

42 

3 

9 

N.  G 

94 

21 

4 

8 

P.G 

100 

26 

4 

15 

A.G 

88 

17 

3 

11 

B.H 

88 

23 

3 

9 

I.H 

91 

33 

3 

4 

P.  K 

72 

2 

5 

J.  K 

104 

28 

3 

4 

A.K 

108 

47 

5 

10 

E.  L 

83 

32 

5 

6 

L.  Le 

105 

36 

4 

10 

J.  L 

110 

33 

4 

6 

H.L 

115 

27 

4 

9 

I  L 

81 
100 

17 
32 

3 
3 

12 

L.  Lu 

3 

L.M 

77 

18 

3 

10 

M.  M 

104 

50 

5 

5 

L.  P 

92 

27 

4 

8 

J.  P 

110 

74 

5 

6 

M.R 

92 

S.  R 

115 

19 

3 

10 

N.R 

103 

41 

3 

10 

I  S 

77 
81 

-2 
0 

1 
1 

8 

H.  Sa 

7 

N.  S 

96 

10 

D.  S 

108 

5 

8 

H.  Sk 

94 

15 

2 

11 

M.T 

93 

51 

5 

5 

H.  U 

100 

47 

4 

4 

N.  W 

90 

37 

3 

11 

J.  Y 

64 

38 

3 

6 

No.  of  cases.. 

37 

32 

34 

36 

Average 

95.46 

32.25 

3.47 

7.89 

o 

12.74 
1.414 

16.09 
1.915 

1.12 
0.1299 

2.84 

P.E 

0.318 

MENTAL  MEASUREMENTS 


173 


TABLE  II 

Control  Group 

First  Grade 


Stanford 

Revision 

I.Q. 

Haggerty 
Score 

Teacher's 
Rating 

M.B 

100 

17 

3 

S.B 

104 

37 

3 

W.  B 

102 

33 

3 

J.  B 

75 

3 

J.  C 

112 

53 

5 

L.  D 

93 

22 

5 

A.  F 

92 

16 

3 

B.  G 

106 

A.  Gl 

86 

15 

3 

G.G 

100 

34 

3 

A.  Go 

89 

20 

4 

S.  H 

111 

34 

4 

D.H 

92 

35 

3 

S.  Je 

87 

35 

3 

S.  Ju 

108 

31 

4 

A.K 

125 

35 

3 

M.L 

109 

F.  L 

84 

10 

2 

L.  P 

102 

28 

3 

I.  P 

101 

38 

4 

A.  P 

79 

12 

2 

F.  P 

109 

38 

3 

W.  S 

88 

45 

3 

H.  Sc 

107 

37 

4 

M.  Sche 

84 

13 

2 

S.  Schn 

84 

S.  Schu 

73 

4 

B.S 

94 

31 

3 

M.  Schw 

61 

1 

M.  St 

100 

33 

3 

H.St 

94 

15 

4 

J.S 

55 

1 

H.  T 

90 

28 

3 

J.  V 

85 

41 

2 

J.Z 

92 

33 

3 

No.  of  cases 

35 

28 

32 

Average 

93.5 

29.25 

3.09 

(T 

14.3 
1.63 

10.73 
1.363 

0  926 

P.E 

0.1102 

174 


HEALTH  EDUCATION 


Comparison  of  Nutrition  and  Control  Groups 

Intelligence  Level. — In  general  intelligence  as 
measured  by  standardized  scales  both  the  under- 
nourished group  and  the  control  group  have  a  nor- 
mal average  rating.  According  to  Terman,  the 
average  group  of  individuals  at  large  make  scores 
that  give  Intelligence  Quotients  between  91  and  110, 
when  rated  by  the  Stanford  Kevision  of  the  Binet- 
Simon  scale. 

Charts  12  and  13  show  the  distribution  of  scores 
in  the  Haggerty  Mental  Examination  and  Stanford 
Eevision  of  Binet-Simon  Intelligence  Tests. 


Validity  of  Difference  between  Nutrition  and  Control 
Groups. 


P.E.D. 

D. 
P.E.D. 

Stanford  Revision  Intelligence  Quotients .  .  . 
Haggerty  Mental  Examination 

2.157 
2.350 
0.1703 

0.901 
1.276 

Teacher's  rating 

2.231 

The  Nutrition  Group  has  an  average  I.  Q.  of 
95.46,  with  a  range  from  64  to  126,  only  four  fall- 
ing below  80.  The  Control  Group  has  a  slightly 
lower  average  of  93.51  with  scores  ranging  from  55 
to  125,  and  five  falling  below  80.  The  scores  for 
the  Haggerty  Mental  Examinations  show  a  similar 
difference  between  the  two  groups  and  are  slightly 
below  the  normal  of  35  for  six  year  old  children. 


MENTAL  MEASUREMENTS 


175 


The  average  rating  given  by  the  teacher  signifies 
good  work.  In  each  group  approximately  a  third 
are  slow,  border-line  cases  or  clearly  defective.  If 
the  cases  who  have  decided  mental  limitations  as 
shown  by  two  or  three  of  the  ratings  were  excluded, 
the  normal  range  of  scores  would  include  all  except 
three  of  each  group,  who  might  be  classed  as  supe- 
rior. When  we  calculate  the  Probable  Error  of  the 
differences  between  the  averages,  we  find  only  in 
Teacher's  Rating  is  there  a  difference  of  as  much 
as  twice  the  Probable  Error.  All  three  measure- 
ments are  consistently  favorable  to  the  Nutrition 
Group,  and  we  seem  justified  in  the  statement  that 
the  superiority  in  intelligence  lies  with  the  under- 
nourished group. 

The  comparison  of  the  gains  in  weight  made  by 
those  having  high  Intelligence  Quotients  and  those 
of  low  Intelligence  Quotients  shows  a  significant  dif- 
ference in  favor  of  the  more  intelligent. 

Gain  in  Weight 


(a)  I.O.>105... 
{h)  T.Q.<  90... 
(c)   Entire  group. 


No.  of  Cases 


9 
32 


Av.  in  Lbs. 


4.54 
3.22 
3.69 


1.247 
1.216 
1.387 


P.E. 


0.2967 
0.2736 
0.165 


Difference  between  (a)  and  (b)  is  3.271  times  its 
Probable  Error;  (a)  and  (c),  2.504;  (6)  and  (c), 
1.464. 


176 


HEALTH  EDUCATION 


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MENTAL  MEASUREMENTS 


177 


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178 


HEALTH  EDUCATION 


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MENTAL  MEASUREMENTS 


170 


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180 


HEALTH  EDUCATION 


Card  sorting. — The  time  and  errors  in  Card  Sort- 
ing were  reduced  in  the  second  trial  by  both  groups, 
but  the  Nutrition  Group  has  better  averages  in  time 
required  and  has  fewer  errors  in  both  trials. 


Probable  Error  of    Difference    (P.E.D.)   between  Scores  of 
THE  Nutrition  and  Control  Groups 


Card  Sorting 

P.E.D. 

D. 

P.E.D. 

Time — First  Trial 

5.307 
2.915 
0.2557 
0.2750 

0.158 

Second  Trial 

1.585 

Errors — First  Trial 

2.335 

Second  Trial 

1.673 

The  difference  between  the  Nutrition  and  Control 
Groups  in  time  required  for  the  first  trials  seems 
insignificant.  More  absolute  improvement  in  rate 
is  shown  by  the  Nutrition  Group  on  the  second  trial. 
The  difference  between  the  averages  is  much  larger, 
and  is  1.585  times  its  Probable  Error.  The  differ- 
ence of  1.27  in  average  number  of  errors  on  the  first 
trial  is  2.335  times  its  Probable  Error,  and  for  the 
second  trial  this  is  only  slightly  less.  This  aggre- 
gate of  differences  in  favor  of  the  undernourished 
group  indicates  a  slight  superiority  over  the  Control 
Group. 

Cylinders. — A  study  of  the  results  in  the  Cylinder 
Test  from  the  standpoint  of  the  total  time  required 
and  of  the  practice  effects  from  one  trial  to  another 
shows  a  more  marked  superiority  of  the  undernour- 
ished group. 


MENTAL  MEASUREMENTS 


181 


Probable  Error  of  Difference    (P.E.D.)   between    Scores  of 
THE  Nutrition  and  Control  Groups 


Cylinder  Test 

P.E.D. 

D. 

P.E.D. 

Time — First  Trial 

19.740 
16.386 
10.471 

2.051 

Second  Trial 

1.276 

Third  Trial 

0.829 

Probable  Error  of  Difference  between  Trials 


Nutrition 

Control 

Cylinder 

P.E.D 

D. 
P.E.D. 

P.E.D. 

D. 

Test. 

P.E.D. 

T1-T2 
T,-T, 

17.317 
14.071 
14.178 

4.464 
1.137 

6.582 

18.93 
13.42 

17.28 

5.12 
2.10 
7.24 

The  time  required  decreases  rapidly  from  first  to 
second  trials  for  both  groups  with  a  smaller  differ- 
ence between  second  and  third  trials.  There  is  a 
greater  absolute  gain  for  the  Control  Group,  which 
has  a  much  larger  initial  time  score,  but  the  percent- 
age of  reduction  shows  greater  improvement  by  the 
Nutrition  Group.  The  differences  in  the  learning 
process  as  shown  by  these  averages  are  significant, 
since  they  are  more  than  four  times  the  Probable 
Error  except  between  second  and  third  trials.  The 
differences  in  averages  of  the  two  groups  for  time 
required  are  not  so  significant,  for  the  second  and 


182 


HEALTH  EDUCATION 


third  trials,  though  the  difference  on  first  trials  is 
more  than  twice  the  Probable  Error,  which  is  cer- 
tainly suggestive. 

CancellaUoyi. — The  Nutrition  Group  has  a  faster 
rate  in  Cancellation  and  makes  fewer  errors. 


Cancellation 

P.E.D. 

D. 
P.E.D. 

Time 

13.410 

1.508 
1.748 

2.514 

Errors — First  Half 

2.029 

Second  Half 

1.865 

The  difference  in  the  averages  of  time  required 
for  the  two  groups  is  two  and  a  half  times  the  Prob- 
able Error  of  this  difference.  The  difference  in  the 
average  number  of  errors  in  the  first  half  of  the 
sheet  is  twice  its  Probable  Error.  The  Nutrition 
Group  shows  no  more  inaccuracy  in  the  latter  half 
of  the  sheet  than  in  the  first  half,  but  the  Control 
Group  has  a  slight  increase  in  the  average  number 
of  errors. 

Action- A  gent. — In  the  test  of  controlled  associa- 
tions there  is  but  little  difference  between  the  two 
groups  in  accuracy.  The  errors  for  both  groups 
were  with  a  few  words,  as  gallops,  growls,  stings, 
which  were  unknown  to  them.  The  Nutrition  Group 
has  a  longer  average  reaction  time.  The  scores 
range  from  1.8  seconds  to  9.8  seconds,  with  an  aver- 
age reaction  time  of  4.5  seconds.  This  is  0.9  seconds 


MENTAL  MEASUREMENTS  183 

longer  than  the  average  for  the  Control  Group,  and 
this  diiference    is  3.378  times  its  Probable  Error. 

There  are  five  in  the  Nutrition  Group  with  slower 
reactions  than  the  longest  reaction  time  for  the  Con- 
trol Group,  two  of  them  exceeding  it  by  2  seconds. 
Among  these  are  three  who  had  low  intelligence 
scores.  The  longest  reaction  times  for  the  Control 
Group  were  made  by  those  having  lowest  intelligence 
scores.  The  inequality  within  the  groups  as  to  intel- 
ligence makes  group  comparison  for  a  study  of  the 
undernourished  child  far  less  valuable. 

A  group  of  50  Italian  boys  of  the  same  age  range 
from  another  public  school  of  New  York  had  an 
average  reaction  time  of  5.9  seconds  for  the  same 
list,  which  is  longer  than  that  for  the  Nutrition 
Group.  Their  accuracy  score  was  8.44  in  compari- 
son with  11.62  for  the  Nutrition  Group.  This  group 
of  undernourished  boys  makes  fewer  errors  and  has 
a  quicker  reaction  time  than  a  group  in  the  same  city 
having  somewhat  similar  home  conditions.  We  do 
not  know,  however,  how  many  of  the  Italians  were 
also  underweight. 

Ship  Test. — In  the  Ship  Test  the  time  scores  in- 
clude so  many  variables  that  the  average  is  of  little 
value.  Some  took  6  minutes  and  made  a  very  good 
score,  others  made  a  score  of  zero  but  completed  it  in 
a  very  short  time.  The  average  score  of  7.26  coin- 
cides with  the  Pintner-Paterson  norm  of  7  to  8  for 
six-year-olds,  so  the  performance  of  these  under- 
nourished boys  is  considered  normal.  The  low 
scores  correlate  more  closely  with  Intelligence  Quo- 
tients than  with  index  of  undernourishment. 


184 


HEALTH  EDUCATION 


SB 

5  a 

e 


MENTAL  MEASUREMENTS  185 

Substitution. — In  the  Substitution  Test  no  norms 
are  available  for  half  sheets,  which  seemed  to  be  a 
desirable  length  to  give  these  young  children  in  com- 
bination with  the  other  tests  used  during  the  period 
of  time  available  for  testing.  There  was  wide  varia- 
tion in  the  time  scores.  The  last  line  used  as  a 
memory  test  for  31  individuals  was  free  from  errors 
in  23  cases,  or  74.2%  of  the  group;  3  or  9.6%  made 
1  error;  2  or  6.5%^  made  2  errors;  2  or  6.5%?  made 
4  errors;  1  or  3.2%  made  5  errors. 

We  find  that  under  conditions  of  work  demanding 
maximal  attention  for  the  best  records  as  to  speed 
and  accuracy,  appreciation  of  relationships,  and  the 
control  of  associational  responses,  the  group  selected 
as  undernourished  make  better  scores  than  the  Con- 
trol Group.  They  also  show  greater  improvement 
in  reducing  the  amount  of  time  required  for  repeated 
performances  together  with  a  higher  degree  of  accu- 
racy. Chart  14  shows  the  significance  of  difference 
between  scores  of  the  two  groups. 

Motor  Coordination  of  Nutrition  Group 

Tapping. — In  the  Tapping  Test  on  Single  Plate 
there  are  marked  individual  variations  as  to  total 
output  and  fatigue  effects.  The  difference  in  actual 
taps  between  the  first  and  third  periods  of  30  sec- 
onds averages  12.3  or  a  fatigue  index  of  4.3%,  when 
this  loss  is  compared  with  the  total  number  of  taps. 
This  can  not  be  directly  compared  mth  an  index  of 
fatigue  determined  by  Gilbert  for  eight-year-olds, 
or  by  Wells  for  adults  because  of  varying  factors  in 


186 


HEALTH  EDUCATION 


TABLE  V 
Nutrition  Group 
First  Grade 


A.  B 

N.C 

B.  D 

S.  Fa 

J.  Fa 

S.  Fi 

J.  Fr 

N.  G 

P.  G 

A.G 

B.  H 

I.  H 

P.  K 

J.  K 

A.  K 

E.  L 

L.  Le 

J.  L 

H.  L 

I.L 

L.  Lu 

L.  M 

M.  M 

L.  P 

J.  P 

M.R 

S.  R 

N.  R 

I.S 

H.  Sa 

N.  S 

D.  S 

H.  Sk 

M.  T 

H.  U 

N.  W 

J.  Y 

No.  of  cases 
Average . . . 

cr 

P.E 


Ship 

Substitution 

Walking 

Target 
Score 

Board 

Total 

Steps 

Off 

Time 

Score 

Time 

Errors 

m  sec. 

m  sec. 

67 

4 

274 

0 

48 

0 

70 

0 

240 

1 

45 

5 

55 

8 

690 

1 

21 

5 

110 

12 

604 

3 

35 

1 

28 

6 

329 

1 

43 

0 

45 

0 

263 

0 

11 

4 

120 

15 

612 

1 

67 

3 

60 

8 

290 

0 

41 

0 

80 

8 

342 

0 

46 

6 

40 

6 

290 

0 

78 

1 

62 

6 

255 

2 

75 

10 

25 

0 

295 

4 

43 

1 

57 

10 

500 

18 

25 

5 

90 

7 

435 

3 

41 

1 

63 

8 

273 

0 

45 

7 

80 

15 

385 

11 

11 

13 

45 

12 

358 

4 

34 

23 

360 

13 

302 

0 

41 

14 

150 

10 

240 

1 

57 

0 

50 

0 

285 

2 

48 

6 

85 

0 

332 

4 

15 

6 

133 

8 

550 

3 

49 

8 

60 

10 

325 

S 

39 

1 

67 

6 

315 

0 

68 

0 

65 

18 

230 

1 

47 

4 

122 

18 

315 

0 

36 

1 

43 

5 

285 

1 

21 

5 

30 

0 

339 

0 

49 

3 

35 

4 

306 

1 

64 

3 

85 

16 

333 

4 

29 

12 

50 

8 

443 

5 

72 

2 

95 

7 

212 

0 

27 

0 

98 

0 

435 

1 

59 

2 

72 

6 

311 

11 

38 

0 

45 

0 

249 

5 

52 

8 

35 

35 

35 

35 

35 

35 

78.34 

7.26 

349.8 

2.31 

43.43 

4.57 

57.32 

5.31 

114.71 

3.95 

17,10 

4.97 

6.534 

0.6053 

13.077 

0.450 

1.949 

0.5668 

MENTAL  MEASUREMENTS 


187 


the  procedure.  The  average  total  output  for  the  first 
30  seconds — 99.8  taps — is  12.2  taps  less  than  the 
score  of  112  for  268  six-year-old  city  boys  given  by 
Pyle  in  the  1920  revision  of  his  manual  for  the  ex- 
amination of  school  children.*  The  loss  from  the 
first  to  the  second  period  and  from  the  first  to  the 
third  period  is  a  valid  difference,  being  more  than 
three  times  the  Probable  Error  in  each  case. 


Probable  Error  of  Difference  between  Averages  for  Tappinq 
Single  Plate 


P.E.D. 

D. 

P.E.D. 

First  30  seconds — Second  30  seconds 

Second  30  seconds — Third  30  seconds .... 
First  30  seconds — Third  30  seconds 

3.269 
3.117 
3.373 

3.319 
0.465 
3.646 

In  Tapping  on  Double  Plate  the  same  loss  is  shown 
and  again  the  differences  are  significant. 


Probable  Error  op  Difference  between  Scores  for  Tapping 
Double  Plate 


First  30  seconds — Second  30  seconds . .  . 
Second  30  seconds — Third  30  seconds .  . 
First  30  seconds — Third  30  seconds.  . . . 


2.537 
2.436 
2.522 


D. 


P.E.D. 


3.532 
0.472 
3.096 


*  Miles,  W.  E.,  Journal  of  Nervous  and  Mental  Diseases,  1919. 
Eeduction  in  neuro-muscular  activities  is  noted  in  subjects  on  low 
diet  with  loss  of  weight. 


188  HEALTH  EDUCATION 

Six  children  of  the  same  age  from  a  private  school 
averaged  138  taps  in  one  minute  or  a  score  of  12 
more  taps  than  the  average  of  126  made  by  the 
Nutrition  Group.  No  other  data  are  available  for 
comparison. 

The  fatigue  effects  as  shown  in  the  Single  Tap- 
ping test  were  compared  with  the  percentages  under- 
weight at  the  time  of  the  test,  and  with  the  gains  in 
weight  during  the  period  of  the  Nutrition  Class  from 
October  to  June.  The  five  cases  showing  most 
fatigue  made  an  average  gain  of  4.42  lbs.,  while  the 
six  cases  showing  least  fatigue  made  an  average  gain 
of  3.43  lbs.  The  difference  between  these  averages 
is  1.816  times  its  Probable  Error. 

At  the  time  of  testing  seven  boys  in  the  most 
fatigued  group  had  an  average  of  7.3%  under- 
weight, w^hile  the  six  in  the  least  fatigued  group 
averaged  6.3%  underweight.  The  difference  between 
these  averages  is  1.15  times  its  Probable  Error. 

The  total  output  in  the  Tapping  tests  for  Single 
and  Double  Plate  forms  was  reckoned  for  groups 
having  specific  physical  defects.  Comparing  these 
averages  with  those  of  the  contrasting  or  normal 
group  we  find  the  differences  shown  in  table  on  op- 
posite page. 

In  each  case  those  of  firm  muscle  tone  and  without 
hyperactive  reflexes  make  better  averages  than  those 
defective  in  these  respects.  The  variability  is  so 
great,  however,  the  differences  are  of  little  signifi- 
cance. 

Primarily  to  obtain  some  check  upon  the  Double 


MENTAL  MEASUREMENTS 


189 


Muscle  Tone 

Reflexes 

Tapping — Single  Plate 

Poor 

Firm 

Hyperactive 

Not 
Hyperactive 

Number  of  cases 

Aver,  number  of  taps 
in  1  ^  min 

10 

280 
45.15 
9.616 

9 

285.44 
52.45 
11   801 

9 

275.89 
45.75 
10.293 

26 
290.42 

(7 

63.42 

P.E 

8 .  371 

P.E.D.-''^^'^ 

D. 

—  =  1.0951 

P.E.D. 

Tapping — Double  Plate 

Number  of  cases 

Aver,  number  of  taps 
in  1  min 

10 

117.8 
24.28 
5.171 
D. 
P.E.D. 

9 

125.44 
20.462 
4.603 

= 1 . 103 

13 

124.54 
21.307 
3.984 
D. 
P.E.D. 

22 
126  91 

0" 

26  37 

P.E 

3  796 

=0.4307 

Form  of  Tapping,  correlation  coefficients  were  com- 
puted. 


Tapping— Single  Plate  with  Double  Plate, r=0.436 

Tapping — Single  Plate  with  Intelligence  Quotient r=:0.316 

Tapping — Double  Plate  with  Intelligence  Quotient t^^O.204: 

Target  Test. — In  the  Target  Test  the  boys  of  the 
Nutrition  Group  made  a  better  score  than  nine  chil- 
dren of  same  age  in  the  private  school. 


190 


HEALTH  EDUCATION 


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MENTAL  MEASUREMENTS 


191 


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192 


HEALTH  EDUCATION 

Target  Test 


Nutrition 

City  and 
Country  School 

Number  of  cases 

Average  score 

34 

43.44 
17.35 
2.013 

9 

27.44 

a 

P.E 

16.92 
3.807 

D. 

=  3.718 

P.E.D. 

These  groups  are  too  unequal  for  valid  compari- 
son, but  in  these  tests  where  no  norms  are  estab- 
lished for  children  of  this  age  indication  of  their 
relative  performances  in  comparison  with  well- 
nourished  children  is  of  interest.  In  the  Target  Test 
they  have  a  significant  superiority. 

Walking  Board. — The  average  number  of  steps  off 
in  walking  the  length  of  the  Board  was  4.57,  with  a 
standard  deviation  of  4.97.  The  scores  of  five  boys 
far  exceeded  those  of  the  remainder  of  the  group. 
Without  their  scores  the  average  number  was  2.93 
and  more  nearly  approaches  the  average  score  for 
five  private  school  children  of  the  same  age,  which 
was  2.6.  A  correlation  of  the  scores  for  Walking 
Board  and  Steadiness  (total  contacts)  gives  r=.157, 
indicating  slight  relationship  between  the  control  of 
arm  and  finger  movement  and  general  bodily  control 
for  this  group. 

Steadiness  Test. — The  control  of  involuntaiy 
movements  was  poor  as  compared  with  the  six  chil- 
dren of  same  age  in  the  private  school. 


MENTAL  MEASUREMENTS 

Steadiness  Test 


193 


Nutrition 

City  and 
Country  School 

Number  of  cases 

Average  hole  reached 

35 
1.23 
0.633 
0.072 

D. 

6 
1.17 

a        

0.362 

P.E 

0.1 

=  0.487 

3.33 

2.36 

Average  number  of  contacts .... 
o 

P.E.D. 

5.14 

3.6 

0.410 

D. 

P.E 

0.649 

=  2.356 

3.83 

Total  contacts 

P.E.D. 

5.54 

4.3 

0.4904 

3.39 

P.E 

0.9322 

^7?^  =  1  623 
P.E.D. 

J)ar]<,  Room. — The  ability  to  keep  the  arm  still 
even  when  supported  is  a  variable,  so  that  we  have 
nothing  more  than  a  suggestion  of  the  reaction  to 
the  dark.  There  is  a  wide  range  of  scores,  and  the 
average  of  9.68  with  a  standard  deviation  of  10.11 
is  not  representative  of  the  group  response.  The 
correlation  of  these  scores  with  the  number  of  total 
contacts  in  the  Steadiness  Test  is  a  negative  one, 
r=  —.161,  but  the  correlation  with  the  Questionnaire 
is  positive,  r=.321. 

Questionnaire. — The  average  number  of  wrong 
answers  to  the  questionnaire  was  7.89  and  is  approx- 


1^ 


HEALTH  EDUCATION 


imately  20%  of  the  total  number  of  questions.  A 
summary  of  the  information  derived  shows  the  fol- 
lowing distribution  of  certain  factors : 

Only  child   2 

Fainted   1 

Afraid  of  dark 17 

Bites  nails  10 

Stutters  or  stammers 2 

Twitches    1 


Favorite  Games 

At  School 

At 

Home 

cards 

guns 

soldiers 

hide  and  seek   (3) 

in  yard 

ball  (3) 

robbers 

robbers 

circle  games   (2) 

checkers    (3) 

tag  (3) 

lion  and  mouse 

acting 

soldier 

cat  and  mouse 

basketball 

horses 

blocks 

hide  and  seek 

fire  engine 

basketball 

school 

ball  (2) 

babies 

puss  in  corner 

pool 

house 

fireman 

blocks   (2) 

circle  gamea 

bucking  boy 

auto 

Pears 

Foods  Disliked 

dark 17 

thunderstorm    11 

crossing  bridge  over  water.  9 

lions   , 7 

water   6 

bear   6 

robbers 4 

loud  noises 6 

rat    3 

horse  5 


potatoes 8 

meat   7 

Boup   5 

milk   2 

oranges    2 

apples    4 

sour  apples 1 

coffee   3 

candy    4 

oatmeal   2 


MENTAL  MEASUREMENTS  195 

Feabs  Foods  Disliked 

negro  2  barley  soup 1 

noises  in  night  3  yellow  food 1 

dog    6  tea   1 

wild  dog 2  cream 1 

wild  animal 2  bananas    2 

fire   5  tomato  soup   1 

crossing  wide  street 3  beets  1 

big  animals    1  cheese    1 

black  animals 1  sour  cream    1 

animals  with  big  horns ....  1  cream  cheese  1 

tiger    2  black  fruits  1 

Bnake   2  canned  salmon 1 

nannie  goats 1  canned  tomatoes   1 

Polack  1  water  1 

going  in  subway 2  bones   1 

automobiles   1  , 

cars 1 

The  number  of  stutterers,  2,  or  5.6%,  is  a 
much  smaller  percentage  of  the  group  than  was 
found  in  a  Nutrition  Class  with  fifth  grade  boys  the 
preceding  year,  when  5  out  of  40,  or  12i/o%,  were 
stutterers.  In  the  entire  grouping  of  75  fifth  grade 
boys,  including  both  a  Nutrition  and  a  Control 
Group,  there  were  11,  or  14.7%,  who  stuttered.  If 
we  can  begin  early  enough  with  such  speech  defects 
we  may  make  headway  towards  the  prevention  of 
such  handicaps  which  occur  more  frequently  in  these 
groups  than  previous  studies  would  lead  one  to 
expect. 

The  number  who  bite  nails,  10,  or  28%,  is  again 
smaller  than  the  fifth  grade  boys,  where  we  found 
14,  or  35%,  of  the  Nutrition  Class  who  had  the  habit 
of  biting  nails,  and  23,  or  30.6%,  of  the  entire  group. 
With  these  first  grade  children,  biting  of  the  nails 
was  caused  in  some  cases  by  lack  of  scissors.    Two 


196  HEALTH  EDUCATION 

boys  spoke  of  trying  knives  and  razors.  Several 
said  they  would  bite  the  nails  off  because  the  mother 
did  not  have  time  to  cut  them.  In  other  cases  there 
seemed  to  be  an  established  habit  of  biting  when 
restless. 

The  fears  of  animals  predominate  in  the  naming 
of  fears.  In  several  cases  the  animals  mentioned 
had  never  been  seen,  as  lion,  wild  animal,  but  de- 
scriptions by  some  child  who  had  been  to  Bronx 
Park  of  their  terrifying  aspects,  or  else  stories  of 
them,  induced  the  belief  that  they  should  be  afraid 
of  such.  We  learned  that  rats  are  a  real  source  of 
annoj^ance  and  fright  in  many  of  the  homes.  Rob- 
beries are  frequently  staged  in  their  block  and  ex- 
citing descriptions  are  often  related  to  them  of 
actual  robberies.  These  facts  were  elicited  upon 
inquiry  as  to  the  causative  factors  of  the  fears.  Such 
factors  also  apply  somewhat  to  other  fears  as  of 
negro,  of  crossing  a  bridge  and  of  lightning  during 
storm.  They  are  not  pathological  fears  but  natural 
fears  caused  by  the  stimuli  that  have  been  presented. 
The  fear  of  the  dark,  however  induced,  is  a  real  one 
in  many  cases.  Three  boys  cried  during  the  short 
period  of  45  seconds  during  which  they  were  in  the 
dark  room  and  when  they  knew  adults  were  just 
outside  the  door.  References  to  moving  pictures, 
both  direct  and  in  dreams,  also  in  play  activities,  in- 
dicate another  source  of  fears.  The  social  investi- 
gator reported  that  all  of  the  children  go  to  the 
''movies"  on  an  average  of  once  a  week,  and  one 
boy  was  taken  by  his  mother  three  times  a  week.  As 
a  group  they  do  not  give  evidence  of  excessive  emo- 
tional instability. 


MENTAL  MEASUREMENTS  197 

Summary 

We  do  not  recognize  these  groups  as  clearly 
enough  differentiated  from  the  standpoint  of  mal- 
nutrition to  be  representative  ones  for  comparisons 
of  the  mental  traits  of  the  undernourished  child 
with  those  of  well-nourished  children.  The  Nutrition 
and  Control  Groups,  however,  are  similarly  selected 
and  are  well  differentiated  in  the  beginning  as  to 
height-weight  indices.  It  is  also  possible  with  many 
of  the  tests  made  to  compare  the  undernourished 
child  with  standards  already  established  on  children 
of  the  same  ages.  It  is  true  that  we  do  not  know 
in  many  cases  how  many  children  are  7%  or  more 
underweight  in  the  groups  used  for  obtaining  the 
norms. 

(1)  In  tests  of  general  intelligence  the  undernour- 
ished children  distribute  themselves  similarly  to 
children  of  normal  height-weight-age  index.  The 
central  tendency  is  slightly  higher  than  that  of  the 
Control  Group  and  there  are  slight  differences  in 
variability.  Children  of  high  intelligence  scores  gain 
more  under  the  Nutrition  Class  procedure  than  those 
of  lower  scores. 

(2)  In  a  learning  series  the  Nutrition  Group  is 
superior  to  the  Control  Group  both  in  speed  and 
accuracy. 

(3)  In  motor  coordination  and  performance  tests 
not  involving  uninterrupted  expenditure  of  muscular 
energy  such  as  Card  Sorting,  Aiming,  and  Dissected 
Pictures,  the  undernourished  children  make  normal 
scores  according  to  established  standards  and  are 
superior  to  the  Control  Group. 


198  HEALTH  EDUCATION 

(4)  In  rate  of  voluntary  movements,  both  simple 
and  complicated  and  continuous  for  an  appreciably 
long  period,  the  output  for  the  first  30  seconds  is  less 
than  that  established  for  children  of  their  age. 
There  is  no  evidence  of  a  higher  fatigue  index  for 
the  children  in  the  Nutrition  Group  who  are  most 
underweight  at  the  time  of  the  tests. 

(5)  This  group  of  undernourished  boys  shows 
sensitivity  to  emotional  stimuli  but  not  exaggerated 
responses  to  the  extent  of  emotional  instability. 


CHAPTER  VIII 

INTERPRETATIONS  AND  RECOMMENDATIONS 
FOR  A  PROGRAM  OF  RESEARCH 

Standards  of  Groivth 

It  will  be  evident  that  our  ability  to  evaluate  re- 
sults from  our  successive  programs  of  experiment 
has  been  rendered  problematical  by  the  existing 
limitations  of  knowledge  as  to  standards  and  laws 
of  growth,  and  that  a  considerable  amount  of  re- 
search must  be  completed  in  this  field  before  the 
evaluation  of  returns  from  the  health  program  can 
be  placed  on  a  scientific  basis. 

Seasonal  nor^ns  must  he  determined.  Such  stand- 
ards as  we  have  are  derived  from  measurements 
taken  without  regard  to  the  factor  of  seasonal  varia- 
tion, which  in  the  case  of  one  of  our  classes  was 
found  to  involve  no  less  than  64.6%  of  the  entire 
yearly  increment  in  the  four  months  from  September 
to  February.  In  view  of  the  facts  established  by 
Dr.  Porter's  investigation  and  sustained  by  our  ex- 
perience, the  need  for  seasonal  norms  becomes 
imperative. 

Before  such  norms  can  be  determined,*  further 
month  to  month  studies  on  large  numbers  of  children 
are  needed  to  secure  more  definite  knowledge  regard- 

*  Dr.  Porter  has  already  raised  the  question  of  the  effect  of  sea- 
sonal variation  on  the  weight  and  height  for  age  of  children  born 
at  different  seasons  of  the  year.     Op.  cit. 

199 


200  HEALTH  EDUCATION 

ing  tlie  periods  of  maximal  and  minimal  weight  in- 
crease. 

Possible  climatic  variation  affecting  seasonal 
norms  in  differing  localities  must  he  anticipated. 
The  causal  factors  of  seasonal  variation  are  un- 
known. The  winter  season  and  confinement  within 
doors  appear  to  offer  at  least  partial  explanation. 
If  these  are  causal  factors,  seasonal  differences  es- 
tablished for  Boston  and  New  York  will  not  be  paral- 
leled in  places  of  such  differing  climatic  character- 
istics as,  for  example  Minneapolis,  New  Orleans,  Los 
Angeles,  Denver,  and  Portland,  Oregon.* 

Tlie  relation  of  the  period  of  minimal  weight  in- 
crease to  vitality  should  he  determined  for  its  hear- 
ing on  the  school  calendar.  This  is  a  question  of 
particular  importance  for  school  procedure  and 
health.  Does  the  period  of  minimal  weight  increase 
indicate  physical  depression?  American  school  tra- 
dition considers  winter  the  period  for  intensive  work, 
and  teachers  generally  depend  on  the  months  inter- 
vening between  the  Christmas  holiday  and  the 
Easter  holiday  as  the  recognized  period  for  speeding 
up  the  learning  process.  It  Avill  be  apparent  that 
the  latter  part  of  this  period  overlaps  the  season 
when  in  our  Northern  communities  at  least,  the  chil- 
dren are  passing  through  the  yearlj^  period  of  mini- 
mal increase  and,  possibly,  of  corresponding  de- 
crease in  vitality.! 

*  Huntington,  Ellsworth,  Civilization  and  Climate,  Yale  University 
Press,  1915. — Investigations  of  climatic  influences  on  vitality  as  shown 
by  industrial  output  are  reported.  See  chart  p.  66,  where  comparison 
is  mado  with  seasonal  weight  increase  shoviTi  by  tuberculosis  patients 
in  the  Adirondacks. 

t  For  a  discTission  of  this  hypothesis  see  Huntington,  Ellsworth, 
op.  cit.  pp.  88-89. 


A  PROGRAM  OF  RESEARCH  201 

In  this  connection  we  may  call  attention  to  the 
slightly  accelerated  height  increase  indicated  by  our 
data  (see  p.  133)  as  coincident  with  the  period  of 
minimal  weight  increase.*  Had  Dr.  Porter's  data 
on  Boston  school  children  shown  a  corresponding 
acceleration  in  height  increase  at  this  period,  the  idea 
of  decreased  vitality  might  be  dismissed  on  the  as- 
sumption that  increase  in  height  is  equally  indicative 
of  vitality,  and  that  periods  of  height  and  weight 
increase  are  alternating.  Previous  to  the  publica- 
tion of  his  initial  report,  however,  Dr.  Porter  had 
found  no  indication  of  seasonal  variation  in  height 
increase. 

The  relation  of  height  increase  to  vitality  and 
nutritional  condition  should  he  more  definitely  deter- 
mined. It  is  common  experience  that  periods  of 
accelerated  height  increase  are  attended  by  a  de- 
crease in  the  proportion  of  weight  for  height,  but 
existing  standards  make  little  allowance  for  a  range 
of  variation  at  such  periods,  or  for  a  range  of  varia- 
tion in  individuals  of  exceptional  height  for  age. 
That  exceptional  height  for  age  may  constitute  in  it- 
self an  index  of  better  nutritional  development,  is  a 
theory  that  seems  sustained  by  the  greater  height 
development  of  the  more  favored  economic  classes 
the  world  over,  as  compared  with  peasantry  and  poor 
of  the  same  racial  stock.  Schiotz  f  has  shown  that 
among  Norwegian  children  this  height  superiority  of 

*  This  is  in  accordance  with  the  conchisions  of  Godin  that  growth 
takes  place  by  alternating  periods  of  height  and  weight  increment. 
Godin,  P.,  Growth  During  School  Age,  Richard  G.  Badger  &  Co.,  pp. 
106-107. 

t  Schiotz,  Carl,  The  Development  of  Children  between  tlie  Ages 
of  Two  and  Six  Years,  Pedagogical  Seminary,  December,  1920,  pp. 
371-397. 


202  HEALTH  EDUCATION 

the  favored  classes  is  attained  by  the  third  year  of 
life  and  is  almost  invariably  attended  by  a  compara- 
tive '' emaciation"  or  decrease  in  the  proportion  of 
weight  for  height.  In  his  opinion  this  condition  is 
the  outcome  of  better  nurture  and  is  indicative  of  an 
accelerated  total  development,  mental  as  well  as 
physical.  Thus  it  is  even  possible  that  early  de- 
velopment in  height  due  to  a  nutritional  status  above 
the  average  may  account  for  a  certain  percentage 
of  the  underweight  reported  among  children  from 
well-to-do  homes  in  this  country.  * 

It  is  probable  that  the  percentage  underweight 
which  may  be  considered  as  constituting  malnutri- 
tion varies  at  differing  age  periods  and  must  be  de- 
termined with  special  reference  to  such  periods. 
Further  studies  of  weight  and  height  increase  at  the 
age  of  school  entrance,  at  the  period  of  the  second 
dentition  and  at  the  periods  of  prepubertal  and  post 
pubertal  development  may  modify  our  present  static 
standards  of  underweight,  77c  or  107o,  as  previous 
studies  have  identified  the  several  age  periods  of 
growth. 

In  a  population  of  mixed  racial  stocks  height- 
weight  standards  must  allow  a  sufficient  range  of 
variation  to  provide  for  differing  racial  characteris- 
tics. The  school  population  at  P.  S.  64  presents  a 
good  illustration  of  racial  variation  differing  from 
accepted  American  standards.  Where  children  of 
similar  stocks  and  of  other  stocks  presenting  as  dis- 
tinct characteristics  are  distributed  through  hetero- 

*  For  a  discussion  of  height  development  as  an  index  of  nutri- 
ional  status  see  Benedict  and  Talbot,  Metabolism  and  Growth  from 
Birth  to  Puberty,  Publication  302,  Carnegie  Institution  of  Washing- 
ton, 1921,  pp.  72-75. 


A  PROGRAM  OF  RESEARCH  203 

geneous  school  populations,  the  significance  of  their 
variation  from  American  standards  is  in  danger  of 
misinterpretation.  Studies  of  growth  with  special 
reference  to  racial  antecedents  are  needed  before  the 
necessary  data  as  to  the  range  of  such  variation  can 
be  determined. 

It  will  be  evident,  however,  that  norms  derived 
from  school  populations  where  economic  and  social 
conditions  are  as  inadequate  as  those  found  in  the 
community  surrounding  P.  S.  64  cannot  be  consid- 
ered true  norms  of  the  racial  stock  represented,  and 
if  progress  in  national  health  is  to  be  our  aim,  norms 
of  well-being  rather  than  numerical  averages  should 
eventually  he  our  determining  standards.  Some 
modifications  of  the  earlier  height-weight-age  scales 
have  already  been  made  on  the  basis  of  school  pop- 
ulations specially  selected  as  representative  of  well- 
developed  children  of  Ajnerican  parentage.*  Fur- 
ther modifications  in  the  same  direction  may  be 
expected  as  the  result  of  recent  studies. f  Children 
of  foreign  parentage  no  less  than  those  of  American 
stock  should  be  held  up  to  standards  of  well-being 
derived  from  measurements  on  well-developed  indi- 
viduals of  their  own  racial  stocks. 

The  susceptibility  of  the  average  family  and  racial 
standards  to  improvement  is  a  fact  that  has  yet  to 
become  a  part  of  national  and  individual  thinking. 
Even  a  few  years,  however,  may  bring  very  radical 
changes  in  our  conceptions  as  to  the  possibilities  of 
such  improvement.    It  is,  for  example,  by  no  means 

*  Baldwin,  Bird  T.,  Physical  Growth  and  School  Progress,  U.  S. 
Bureau  of  Education  Bulletin,  No.    10,   1914. 

t  For  a  discussion  of  '  *  Normal  average,  and  ideal  states  of  nutri- 
tion," see  Benedict  and  Talbot,  Op,  cit.,  p.  69. 


204  HEALTH  EDUCATION 

clear  how  far  the  facts  of  seasonal  variation  uncov- 
ered by  Dr.  Porter  must  be  accepted  as  natural  laws 
of  growth,  and  how  far  they  may  be  attributed  to 
inadequate  environmental  factors  affecting  the  de- 
velopment of  the  great  majority  of  Boston  children 
of  school  age.  Month  to  month  studies  of  even  a 
small  group  of  children  living  under  corresponding 
climatic  conditions  hut  in  carefully  controlled  envi- 
ronmental surroundings  might  offer  valuable  sug- 
gestions in  this  direction.  Certainly  we  must  con- 
cede that  the  present  scale  of  living  in  the  great 
majority  of  homes  is  decidedly  below  the  optimum 
so  far  as  habits  regarding  food,  fresh  air  and  sleep 
are  concerned. 

Causal  Factors  and  Individual  Response 

The  importance  of  environment  and  the  scale  of 
living  must  not  lead  us  to  ignore  the  part  played 
by  other  factors  in  causing  underweight,  and  the  sig- 
nificance these  may  have  as  determining  relative  suc- 
cess or  failure  in  securing  gains.  It  will  be  evident 
that  the  children  in  the  groups  studied  by  us  ex- 
hibited a  wide  variation  in  their  response  to  the 
program  of  treatment.  While  response  for  the  indi- 
vidual was  largely  dependent  on  the  circumstances 
of  his  environment  and  the  extent  of  his  cooperation, 
his  ability  to  respond  was  conditioned  by  the  causal 
factors  of  his  underiveight.  These  causal  factors 
may  be  classified  in  at  least  five  groups,  and  it  is 
probable  that  any  study  of  underweight  school  chil- 
dren comparable  with  ours  as  to  numbers,  will  have 
to  deal  as  we  did  with  representatives  from  each 
group. 


A  PROGRAM  OF  RESEARCH  205 

(1)  Children  showing  results  of  faulty  hygiene 
and  diet  due  to  home  ignorance  or  lack  of  control. 
Probably  a  considerable  majority  in  any  school  pop- 
ulation. 

(2)  Hungry  cases — candidates  for  relief  and 
occasional  cases  where  individual  or  parental  idio- 
syncrasy prevents  adequate  food  intake. 

(3)  Children  showing  unusual  fluctuations  because 
of  special  circumstances  as  in  the  case  of  convales- 
cents. 

(4)  Children  having  wasting  diseases,  probably  in 
the  incipient  stage.  Pre-tubercular  cases  were 
fairly  numerous  in  our  experience  and  the  possi- 
bility of  such  maladies  as  syphilis,  diabetes,  chronic 
nephritis,  malaria,  intestinal  parasites,  must  always 
be  reckoned  with.* 

(5)  Children  showing  a  past  history  of  chronic 
nutritional  disorders  or  of  diseases  commonly  re- 
sulting in  impaired  nutrition.  The  so-called  ''chil- 
dren's diseases"  are  responsible  for  many  such 
disorders.  Premature  birth,  malnutrition  of  the 
mother  during  pregnancy,  difficult  feeding  in  the  first 
year  of  life,  severe  repeated  gastro-intestinal  at- 
tacks, may  all  result  in  chronic  impairment  of  the 
nutritional  processes.  Change  or  deficiency  in  some 
of  the  internal  secretions  may  be  cited  in  connection 
with  this  type  of  causal  factors.  It  will  be  evident 
that  a  number  of  the  children  treated  in  our  open- 
air  classes  belong  to  this  group. 

Throughout  our  experience  the  ability  to  respond 
has   been   pretty   consistently   demonstrated   to   be 

•  See  Smith,  Charles  Hendee,  Methods  Used  in  a  Class  for  Under- 
nourished Children,  Am.  Jour,  of  Diseases  of  Children,  June,  1918. 


206  HEALTH  EDUCATION 

greater  on  the  part  of  children  in  the  first  three 
groups  than  among  those  of  groups  4  and  5.  At 
the  same  time  the  majority  of  the  high  percentile 
cases  have  been  found  among  the  latter  groups  and 
the  records  of  our  lower  percentile  cases  show  for 
the  most  part  better  average  gains  in  proportion  to 
better  nutritional  status.  ( See  pp.  134  and  151,  discus- 
sion of  relative  gains  and  varying  degrees  of  under- 
weight.) Thus  the  facts  of  our  experience  do  not  at 
first  glance  support  the  assumption  held  by  many 
social  workers,  especially  those  connected  with 
orphanages  and  temporary  homes  for  neglected  chil- 
dren, that  the  high  percentile  cases  respond  more 
readily,  and  that  results  of  treatment  are  less  evi- 
dent as  children  approximate  normal  weight.  If  allow- 
ance is  made,  however,  for  the  probable  difference 
in  the  response  afforded  by  high  percentile  cases 
from  group  2  (hungry  cases),  and  by  high  per- 
centiles from  groups  4  and  5,  this  apparent  discrep- 
ancy is  easily  reconciled.  Statistical  data  from  re- 
lief agencies  whose  cases  are  largely  drawn  from 
group  2  would  doubtless  only  serve  to  confirm  our 
experience  that  causal  factors  rather  than  degree  of 
underweight  determine  the  individual  ability  to 
respond. 

Major  defects  mag  be  contributing  factors  and  as 
such  influence  response.  The  effect  of  tonsil  and 
adenoid  obstructions  on  individual  ability  to  respond 
has  been  amply  demonstrated.  Our  experience  can 
be  said  to  offer  nothing  new  in  respect  to  these 
defects  except  as  it  argues  success  for  securing  such 
treatment  through  the  agency  of  the  school. 

The  interrelation  of  dental  caries  and  malnutri- 


A   PROGRAM  OF  RESEARCH  207 

tion  needs  to  be  more  definitely  determined.  The 
theory  that  mahiiitrition  is  a  cause  and  an  im- 
portant cause  of  dental  caries,  though  highly  prob- 
able and  widely  accepted  has  never  been  conclusively 
proved.  On  the  other  hand,  the  lack  of  obvious  re- 
sults in  weight  increase  attending  correction  of  the 
defect,  apparently  disproves  the  theory  that  dental 
caries  is  a  chief  causal  factor  of  malnutrition.  For 
these  reasons  health  workers  have  often  minimized 
the  importance  of  dental  caries,  but  in  the  absence 
of  conclusive  proof  to  the  contrary,  its  possibilities 
as  a  contributing  factor  to  the  condition  of  malnu- 
trition cannot  be  ignored.  We  must  assume  that  in 
addition  to  diminishing  chewing  surface,  its  presence 
may  lower  general  vitality  and  powers  of  resistance, 
either  through  the  introduction  of  toxins  into  the 
system  or  by  presenting  possible  sources  of  bacterial 
infection. 

Previous  duration  of  the  condition  of  malnourish- 
ment  may  he  to  some  extent  an  index  of  the  response 
to  be  expected.  "Where  the  physical  examination 
reveals  signs  of  rickets  or  other  of  the  nutritional 
diseases  of  infancy,  we  may  be  justified  in  expecting 
relatively  better  response  from  the  first  grade  child 
than  from  the  sixth  grade  child,  for  example.  The 
response  shown  by  our  first  grade  children  may  be 
partly  explained  by  this  assumption  *  and  the  grow- 
ing emphasis  placed  by  physicians  on  corrective 
work  for  children  of  pre-school  age  becomes  of  addi- 
tional importance  if  it  be  true. 

*  That  long  continued  or  extreme  conditions  of  malnourishment  may 
result  in  actual  organic  changes  has  been  shown  by  the  recent  in- 
vestigations of  von  Pirquet  in  Vienna.  A  remarkable  elongation  of 
the  intestine  was  found  in  children  subjected  to  famine  conditions. 


208  HEALTH  EDUCATION 

Moreover,  undiagnosed  conditions  of  disease  and 
pliysiological  facts  as  yet  hut  little  understood  must 
he  anticipated  as  possihle  causal  factors.  The  group 
of  chronic  underweights  reported  in  our  open-air 
class  of  1919-20  for  whom  no  diagnosis  was  obtained, 
and  who  failed  to  respond  in  any  degree  to  treat- 
ment, are  representative  of  these  problem  cases 
whose  causal  factors  need  to  be  determined  by  fur- 
ther medical  research. 

That  undiagnosed  incipient  tuberculosis  may  con- 
stitute a  causal  factor  in  a  large  percentage  of  mal- 
nutrition cases  is  a  theory  advanced  by  some  phy- 
sicians. The  routine  use  of  von  Pirquet  Tests  on 
large  groups  of  underw^eight  children  should  furnish 
data  to  confirm  or  refute  this  hypothesis,  as  com- 
parison with  the  percentage  results  previously  ob- 
tained by  the  same  tests  on  average  school  children, 
would  establish  the  relative  frequency  of  positive 
reactions  among  the  underweight  group. 

At  the  same  time,  it  is  to  be  hoped  that  further 
research  may  be  successful  in  determining  the  rela- 
tion of  diet  as  a  predisposing  factor  to  tuberculosis. 
The  experience  of  the  war  has  amply  proved  that 
insufficient  diet  is  followed  by  corresponding  in- 
crease in  tuberculosis,  but  has  thrown  no  light  on 
the  relative  part  played  by  lowered  caloric  intake, 
and  the  deprivation  of  special  food  factors  as  fats, 
vitamines,  and  mineral  constituents,  as  lime  or  phos- 
phorus. Careful  laboratory  experiment  along  this 
line  of  inquiry  should  yield  important  results  for  the 
preventive  program. 

Latent  syphilis  has  been  reported  as  a  causal  fac- 
tor in  a  considerable  percentage  of  cases  treated  at 


A  PROGRAM   OF  RESEARCH  209 

one  clinic,  and  further  research  may  establish  that 
this  is  a  causal  factor  in  a  much  larger  number  of 
cases  than  is  now  generally  recognized. 

It  is  probable  that  better  knowledge  of  the  part 
played  in  metabolism  by  the  ductless  glands  would 
throw  light  on  many  problems  of  malnutrition.  For 
example,  the  question  may  be  raised  whether  an  in- 
creased thyroid  activity  was  not  involved  in  the  case 
of  the  underweight  children  from  the  Terman  classes 
(pp.  29  and  54). 

The  part  played  by  emotional  disturbances  and 
their  effect  on  digestion  has  been  pretty  thoroughly 
demonstrated  by  laboratory  research,*  and  the  tes- 
timony of  nutrition  workers  corroborates  its  im- 
portance in  cases  Avhere  unwise  discipline,  family 
friction  or  worry  are  characteristic  of  the  home 
environment.!  The  fluctuations  shown  by  the 
growth  chart  of  the  fifth  grade  (p.  86)  indicate 
probable  effects  of  worry  or  excitement  during  ex- 
amination week  and  parade  week. 

The  scientific  interest  attaching  to  these  little 
known  factors  and  the  variety  of  the  morbid  condi- 
tions affecting  nutrition  must  not  mislead  us,  how- 
ever, in  regard  to  the  large  percentage  of  ''straight'^ 
nutritional  cases  whose  response  is  dependent  on 
the  facts  of  their  daily  regime.  For  obvious  reasons 
we  may  expect  the  relative  percentage  of  such  chil- 
dren to  be  greater  in  the  school  nutrition  class  than 
in  the  hospital  clinic.  The  facts  of  the  physical  ex- 
amination and  the  investigation  of  individual  his- 

•  Cannon,  W.  B.,  Op.  cit. 

t  Mitchell,  David,  Malnutrition  and  Health  Education,  Pedagogical 
Seminary,   March,    1920,  pp.  65-66. 


210  HEALTH  EDUCATION 

tory  should  serve  to  identify  the  majority  of  children 
with  one  of  the  five  groups  enumerated,  at  the  out- 
set of  any  nutritional  program,  and  provide  sugges- 
tions as  to  individual  modifications  mth  respect  to 
physical  care  and  regime.  Stool  and  urine  examina- 
tions should  be  included  wherever  possible  as  an  aid 
to  diagnosis. 

Further  stool  examinations  on  large  numbers  of 
undernourished  children  should  be  undertaken  to  de- 
termine the  frequency  of  special  types  of  indigestion 
and  for  further  investigation  of  parasites.  Such 
a  piece  of  research  would  undoubtedly  afford  sug- 
gestions as  to  corrective  and  preventive  procedure 
with  children  from  Group  (1)  as  well  as  from 
Groups  (4)  and  (5).  Further  urine  examinations 
for  large  groups  of  underweight  children  should 
prove  helpful  in  disclosing  latent  disease  in  relation 
to  malnutrition. 

Psychological  Implications 

It  is  often  stated  that  a  causal  relationship  exists 
between  mental  defectiveness  and  malnutrition. 
Bryant*  says  *'the  relation  of  malnutrition  to  men- 
tal defectiveness  has  long  been  given  substantial 
recognition  both  here  and  abroad  in  the  provision 
of  lunches  in  special  schools  for  subnormal  chil- 
dren. '  *  The  most  frequently  used  method  of  deter- 
mining this  relationship  in  the  investigations  cited 
by  her  has  been  the  calculation  of  the  percentage  of 
mental  defectives  that  show  malnutrition.  In  some 
cases  the  criterion  of  mental  defectiveness  was  fail- 
ure to  be  promoted,  and  no  other  factors  such  as 

*  Bryant,  L.  S.    School  Feeding,  J.  B,  Lippincott  Co.,  1913,  p.  225. 


A  PROGRAM  OF  RESEARCH  211 

specific  physical  disabilities  or  attendance  were  con- 
sidered as  causal  in  the  retardation.  If  one  were 
looking  for  tlie  percentage  of  malnutrition  in  very- 
bright  children,  and  should  take  from  psychological 
data  obtained  in  the  investigation  of  large  groups 
of  school  children  the  scores  'of  those  \%  or  more 
underweight,  we  might  have  a  very  different  story. 
The  ''pale  brow  of  the  scholar"  would  doubtless 
get  some  statistical  justification. 

In  the  Terman  *  class,  a  group  of  high  intelligence 
quotients,  there  was  a  smaller  per  cent  of  children 
7%  or  more  overweight  and  a  larger  per  cent  of 
children  7%  or  more  underweight  than  in  any  of 
the  other  classes  studied  during  that  year  (1918). 

Discussing  the  possibility  of  mental  defect  being 
caused  by  defective  bodily  nutrition  and  the  depend- 
ence of  the  physical  health  and  development  of  the 
growing  child  upon  the  quantity  and  quality  of  his 
food,  the  presence  of  an  adequate  amount  of  sleep, 
fresh  air,  light,  warmth,  etc.,  Tredgold  f  states  that 
''on  the  whole  it  may  be  said  that  these  factors  in 
the  absence  of  hereditary  predisposition  have  com- 
paratively little  causal  influence  .  .  .  rickets  is 
sometimes  the  accompaniment  of  mental  deficiency 
but  I  doubt  whether  it  is  ever  its  cause." 

Blanton  %  made  a  study  of  the  mental  and  nervous 
conditions  of  school  children  between  the  ages  of  5^ 
and  14  years,  40-50%  of  whom  were  supposed  to 
have  suffered  from  malnutrition  for  a  period  of  two 

*  See  p.  60. 

t  Tredgold,  A.  F.,  Mental  Deficiency,  Wm.  Wood,  3rd  Ed.,  pp.  63-64. 

t  Blanton,  Smiley.  Mental  and  Nervous  Changes  in  the  Children 
of  the  Volls-schvlen  of  Trier,  Germany,  Caused  hy  Malnutrition. 
Mental  Hygiene,  July,  1919. 


212  HEALTH   EDUCATION 

or  three  years.  He  made  no  careful  mental  measure- 
ments but  depended  primarily  upon  clinical  ex- 
aminations, observations  in  the  schoolroom  and  per- 
sonal histories  given  by  families  and  teachers 
through  an  interpreter.  He  concludes  that  ''Chil- 
dren free  from  organic  nervous  disease  and  with 
parents  of  average  intelligence  very  rarely  become 
feeble-minded  through  malnutrition  even  of  an  ex- 
treme degree."  One  of  the  most  important  things 
shown  in  this  whole  study  is  how  the  nervous  sys- 
tems of  children  of  good  nervous  stock  can  resist 
malnutrition  of  an  extreme  degree  extending  over 
three  years. 

We  believe  that  the  more  direct  method  of  attack 
is  the  better.  We  should  like  to  see  the  problem 
followed  up  by  careful  measurements  as  to  intel- 
ligence levels,  reaction  times,  attention,  and  memory 
spans,  motor  control  and  the  learning  process  upon 
children  who  are  chronically  underweight  to  the  ex- 
tent of  15%  or  more,  with  a  control  group  of  children 
w^hose  height-weight  indices  are  normal  or  above 
normal.  This  should  be  done  for  varying  ages.  Do 
we  know  that  15  7o  underweight  at  7  means  the  same 
thing  as  15%  underweight  at  11  or  at  17?  With  the 
present  trend  toward  exact  physical  and  mental 
measurements  of  all  children,  not  neglecting  the 
normal  child  who  has  seemed  primarily  a  statistical 
will-o  '-the-wisp,  we  can  best  develop  criteria  of  mal- 
nutrition. Aside  from  extreme  cases  of  malnutri- 
tion, of  prolonged  hunger  or  starvation  which  like 
other  pathological  states  would  cause  disintegration, 
we  cannot  say  that  malnutrition  irrespective  of  other 
factors  produces  or  runs  hand  in  hand  with  mental 


A  PROGRAM  OF  RESEARCH  213 

defectiveness.  In  many  types  of  mental  processes 
the  reactions  of  the  undernourished  child  are  equal 
or  superior  to  the  average  of  his  age  group.  The 
traits  in  which  he  may  prove  less  capable  seem  to  be 
resistance  to  fatigue  under  response  to  uninter- 
rupted or  complex  stimuli,  and  exaggerated  emo- 
tional responses  under  normal  stimulation.  A  prob- 
lem worthy  of  stud}^  both  for  the  undernourished 
and  for  the  hearty  child  is  fatigue  with  special  ref- 
erence to  the  period  of  recovery. 


F 


»     •     •     e     »     •     •uuuuMua0«M»sSD     m     db«» 


6S 
84 
83 
82 

81 

80 
49 
48 
47 
46 
45 
44 
43 
42 
41 


Chart  of  low  percentile  case  showing  excellent  response.  Boy 
6  yrs.  of  age,  Austrian  father,  Russian  mother.  Underweight 
8%  Sept.  1 9 19;  2%  May  1920;  normal  weight  Sept.  1920- 
Phy steal  history  shows  measles  (8  mos.),  anti-toxin  given  for 
suspected  diphtheria,  bad  tonsil  condition.  Mental  history 
shows  high  intelligence,  I.  Q.  126  (Terman).  Social  history 
shows  father  short,  medium  build,  mother  medium  height, 
plump.  Family  of  8 ;  flat  of  5  outside  rooms,  6  windows. 
Comfortable  well-icept  home,  mother  a  "good  cook,"  Note:  a 
case  of  special  interest  where  the  child's  determination  to  follow 
an  imposed  regime  resulted  in  later  enlistment  of  the  mother's 
cooperation.  Tonsillectomy  recommended  Oct.  191 9;  per- 
formed Dec.  1920. 

214 


H 


Hrohi 42 

w-ikL 34 


41 

7 


DOS       MaBIIBItB 


45 
44 
43 
43 
41 
40 

39 
38 
37 
36 
35 
34 
33 
32 
31 


"VA, 


Chart  of  high  percentile  case  showing  unsatisfactory  response. 
Boy  6  yrs.  of  age,  Austrian  parentage.  Underweight,  I7%- 
Sept.  1919;  12%  May  1920;  16%  Sept.  1920.  Physical  history 
shows  measles  (2  yrs.)  chicken  pox  (3  yrs.)  "convulsions"  (2-4 
yrs.),  chronic  digestive  disturbances  apparently  due  to  unwise 
home  regime,  especially  as  to  habits  of  eating.  Mental  history 
shows  I.  Q.  91  (Terman).  Social  history  shows  father  thin 
delicate  type,  mother  5  ft.,  7%  underweight;  family  of  6;  flat 
of  4  small  rooms,  rrround  floor,  poor  ventilation.  Entire  family 
suffering  from  digestive  troubles:  Note:  lack  of  home  coopera- 
tion and  duration  of  unsatisfactory  conditions  seem  responsible 
for  failure  to  improve. 

215 


ejA 


I! 


'4r 


Chart  of  high  percentile  case  showing  unusual  response.  Boy 
6  5'rs.  of  age.  Father  Russian  Pole;  mother,  Austrian.  Under- 
weight, 20%  Sept.  1919;  9%  May  1920;  9%  Sept.  1920. 
Physical  history  shows  small  size  at  birth  (4^  lbs.),  measles 
(13^  yrs. ),  whooping  cough  (5  yrs.),  German  measles  (5  yrs.). 
Mental  history  shows  I.  Q.  108  (Terman),  evidences  of  emo- 
tional instability.  Social  history  shows  parents  divorced,  mother 
and  child  living  with  grandparents,  mother  5  ft.  2  in.  tall,  13% 
overweight,  only  child,  family  of  9  adults,  flat  of  5  rooms, 
fairly  large,  all  outside  windows;  comfortable  economic  circum- 
stances. Note:  Cooperation  of  mother  and  child  successfully 
enlisted. 

216 


K 


,.6  cj^lA. 


55 
54 
53 

52 
51 

50 
49 
48 
47 
46 
45 
44 
43 
43 
41 


Chart  of  low  percentile  case  showing  excellent  response.  Boy 
of  6  yrs.  of  age.  Russian  parentage.  Underweight  8%  Sept. 
1919;  2%  above  normal  May  1920;  2%  below  normal  Sept. 
1920.  Physical  history  shows  whooping  cough  (8  mos.), 
measles  (i  yr.),  pneumonia  (2  yrs.),  tonsillectomy  (5  yrs.). 
Mental  history  shows  I.  Q.  104  (Terman),  Social  history 
shows  father  short,  5%  overweight;  mother  short  13%  over- 
weight ;  family  of  6 ;  flat  of  4  rooms,  light,  well-ventilated,  well- 
kept.  Note:  Cooperation  of  parents  willing  but  rather  unin- 
telligent. 

217 


37 
36 
35 


R 


„6  c,  .lA 


Chart  of  case  12%  underweight  showing  excellent  response. 
Boy  of  6  yrs.  of  age,  Russian  parentage.  Underweight  12% 
Sept.  1919;  normal  weight  May  ist,  1920;  4%  underweight 
Sept.  1920.  Physical  history  shows  diphtheria  (3  yrs.)  ;  measles 
(4  yrs.)  ;  chicken  pox  (4  yrs.)  ;  frequent  sore  throats  due  to 
enlarged  tonsils,  cardiac  symptoms,  imperative  need  of  dental 
care.  Mental  history  shows  I.  Q.  92  (Terman).  Social  history 
shows  father  short  (5  ft.),  slight  (circ.  6%  underweight); 
mother,  medium  height,  normal  weight.  Family  of  7 ;  flat  of  4 
rooms;  all  windows  on  a  court.  A  comparatively  comfortable, 
well-kept  home.  Note:  Cooperation  of  parents  resulted  in  cor- 
rection of  dental  defects  and  tonsillectomy. 

218 


s 


t^-- 14 


47 

46 

45 

44 

43 

43 

41 

40 

39 

38 

37 

36 

35 

34 

33 


Chart  of  high  precentile  case  showing  unsatisfactory  response. 
Boy  6  yrs.  of  age,  Russian  parentage.  Underweight,  1 6%  Sept. 
1912;  11%  May  1920;  S%  Sept.  1920.  Physical  history  shows 
small  size  at  birth  (4  lbs.)  pneumonia  in  infancy,  adenoid  opera- 
tion (3  yrs.)  ;  bronchitis  frequently,  cardiac  symptoms  present. 
Mental  history  shows  I.  Q.  108  (Terman).  Evidences  of  nerv- 
ous instability  and  development  of  chorea.  Social  history  shows 
father  short  (5  ft.),  lo'/i  overweight;  mother,  medium  height, 
overweight.  Family  of  three ;  flat  of  3  rooms,  I  northern  ex- 
posure, 2  on  court.  Home  fairly  comfortable  and  well-kept. 
Note:  Primarily  a  medical  case.  Cooperation  of  mother  un- 
usually good.  Hospital  care  for  chorea  began  July  1 920.  Child 
kept  constantly  in  bed,  did  not  return  to  school  192021. 

219 


N 


tt 


9v  Cwv  U<^r»«^ 


a 


47 
48 
45 
44 
43 
42 
41 
40 
39 
38 
37 
36 
35 
34 
33 


Chart  showing  failure  to  respond.  Boy  6  yrs.  of  age.  Russian 
parentage.  Underweight,  io%  Sept.  1919;  9%  May  1920; 
11%  Sept.  1920.  Physical  history  shows  small  size  at  birth 
(3/^  lbs.);  he  was  the  smaller  of  twin  brothers;  14  months 
teething;  chicken-pox  (13^  yrs.),  measles  (23^  yrs.),  Mental 
history  shows  evidences  of  retarded  development  and  infantile 
attitudes.  I.  Q.  77  (Terman)  ;  has  failed  of  promotion  during 
two  years  of  schooling.  Social  history  shows  father  short  (5  ft.), 
normal  weight  for  height;  mother  5  ft.,  21%  overweight  for 
height ;  family  of  7 ;  3  adults,  crowded  home,  3  small  rooms 
opening  on  court.    Note:  cooperation  of  mother  willing. 

220 


CHAPTER  IX 

INTERPRETATIONS  AND  RECOMMENDATIONS 
FOR  AN  EDUCATIONAL  PROGRAM 

Wlien  we  review  the  experiment  at  P.  S.  64  in  its 

entirety  and  contrast  the  program  offered  by  the 
nutrition  class  with  the  traditional  school  attack 
on  health  problems,  the  emphasis  placed  on  de- 
monstrable results  for  well-being  must  be  recognized 
as  the  outstanding  contribution  the  experience  has 
afforded  toward  the  conception  of  a  general  educa- 
tional procedure.  That  health  education  must  he 
rendered  susceptible  of  evaluation  is  the  challenge 
of  the  nutrition  class  to  the  school.  All  the  diffi- 
culties encountered  in  our  attempt  to  secure  appre- 
ciable results  and  to  evaluate  them  correctly  do  not 
lessen  this  emphasis  on  their  importance  for  the 
positive  health  program. 

Principles  Determining  Results 

It  will  be  evident  therefore  that  whatever  addi- 
tional suggestions  the  experience  may  offer  toward 
the  shaping  of  a  school  health  program  must  be 
determined  in  accordance  with  this  first  and  fund- 
amental consideration  of  returns  secured.  If  we  sub- 
ject our  record  to  the  test  of  appreciable  results, 
what  principles  emerge  as  governing  the  success  of 
an  educational  procedure  for  health  making?  Ap- 
parently we  must  concede  the  importance  of  the 
following : 

221 


222  HEALTH  EDUCATION 

Gains  liave  been  largely  dependent  on  initial 
physical  status  and  proportionate  to  the  rela- 
tively superior  or  inferior  condition  of  the  in- 
dividuals considered. 

Gains  have  been  largely  influenced  by  the 
technique  employed  for  enlisting  cooperation 
from  the  children. 

Other  conditions  being  equal  gains  have  been 
in  direct  proportion  to  the  influence  exerted  on 
the  home  and  the  resulting  parental  cooperation. 

Gains  appear  to  have  been  appreciably  in- 
creased when  favorable  conditions  directly  af- 
fecting the  nutritional  processes  have  been  in- 
troduced within  the  school  environment. 

The  first  of  these  tentative  findings  is  of  special 
significance  for  its  bearing  on  the  possible  value  of 
our  procedure  as  a  preventive  program  by  which 
the  well-being  of  the  normal  child  may  be  increased. 
Certainly  the  results  shown  in  those  groups  most 
carefully  observed  by  us  suggest  that  so-called 
normal  children,  and  children  approximating  cur- 
rently accepted  norms  may  benefit  hy  the  procedure 
in  proportion  to  their  superior  physical  condition. 
The  comparative  gains  made  by  Sections  I  and  II 
of  the  fifth  grade  boys  may  be  cited  in  this  connec- 
tion. It  has  been  shown  (p.  154)  that  the  22  children 
of  this  class  who  ''graduated"  in  the  fall  of  1918 
(Section  II)  averaged  in  two  years  a  gain  of  3.6 
pounds  more  than  the  Wood  norms  and  of  4.1  pounds 
more  than  the  Porter  norms  for  boys  of  their  age 
and  height.    This  is  an  average  of  2.61  pounds  more 


AN   EDUCATIONAL  PROGRAM  223 

than  that  gained  by  the  remaining  members  of  the 
group  (Section  I)  who  were  children  averaging  a 
greater  degree  of  underweight  and  who  gained  in  the 
same  period  an  average  of  .99  pound  more  than  the 
Wood  norms  and  1.49  pounds  more  than  the  Porter 
norms.  SimiLirly,  Section  I  of  the  first  grade  chil- 
dren (1919-20  program)  those  8-9%  underweight 
gained  an  average  of  nearly  5  pounds  more  from 
October  to  October  than  the  children  of  the  sections 
respectively  10-12%  and  13-20%)  underweight. 

The  record  of  gains  shown  by  the  fifth  grade  boys 
at  the  end  of  two  years,  fourteen  months  after  the 
period  of  their  instruction  had  been  discontinued, 
is  one  of  the  most  striking  facts  of  the  entire  ex- 
perience.*  It  is  unfortunate  that  corresponding  fol- 

*  As  the  great  majority  of  the  children  considered  were  of  Jewish- 
Russian  or  of  Jewish-Austrian  parentage  tlie  question  of  racial  or 
8tock  variation  in  relation  to  physiological  age  may  be  raised  in 
connection  with  these  figures  for  gains  between  11  and  13  years  of 
age.  There  are,  however,  no  existing  norms  from  which  we  may 
determine  how  far  earlier  pubescence  and  attendant  variations  in 
height  and  weight  must  be  considered.  The  weights  of  68G  Jewish 
boys  14  years  of  age  who  were  granted  working  papers  in  New 
York  City  between  July,  1914,  and  April,  1915,  were  found  to  average 
2  pounds  above  those  of  14  year  old  boys  of  other  racial  antece- 
dents (Frankel  and  Dublin,  Heights  and  Weights  of  Ne%v  York  City 
Children,  Metropolitan  Life  Insurance  Co.,  1916).  This  average  was 
obtained,  however,  without  discrimijiation  as  to  national  antecedents, 
whether  Jewish-German,  Jewish-Russian,  Jewish-Polish,  or  other,  and 
beyond  raising  the  question  of  racial  variation  and  physiological  age 
throws  no  light  on  standards  for  Jewish-Russian  and  Jewish-Austrian 
boys  between  the  ages  of  11  and  13. 

Twenty-five  boys  of  our  Control  Group,  organized  in  September,  1918, 
were  observed  through  18  months,  to  June,  1920,  during  which  period 
their  average  weight  closely  approximated  the  Burke-Boas  norms  for 
the  given  heights  from  11  to  12^^  years.  The  gain  averaged  by  tho 
Control  Group  for  this  period  was  12.11  pounds,  that  of  Section  I, 
12.25  pounds  or  .13  pound  more  than  the  control  and  that  of  Section 
II  15.37  pounds  or  3.26  pounds  more  than  the  control.  Thus  at 
12%  years  the  average  gains  of  Section  II  in  excess  of  the  control 
group  do  not  differ  materially  from  the  gains  shown  by  them  six 
months  later  (3.6  pounds)  in  excess  of  the  Wood  norms.  From  the 
data  available  it  would  appear  that  the  superior  weight  increase  of 
this  group  was  presimiably  duo  to  a  better  regime. 


224  HEALTH  EDUCATION 

low-up  records  were  not  attempted  for  all  our  groups 
especially  for  the  children  of  the  open-air  and  Ter- 
man  classes,  for  the  possibilities  they  might  have 
afforded  for  further  suggestions  as  to  comparative 
long  term  results.  It  will  be  evident,  however,  that 
a  procedure  affording  gains  for  children  who  ap- 
proximate normal  development,  and  resulting  in  con- 
tinued gains  subsequent  to  the  period  of  instruction, 
is  calculated  to  meet  the  fundamental  requirements 
of  the  educational  ideal,  a  health  program  that  shall 
combine  preventive  possibilities  with  those  more  im- 
mediate and  corrective  in  character. 

The  technique  for  enlisting  group  interest  and  ac- 
tion must  he  the  first  consideration  in  the  conduct 
of  the  health  procedure.  Save  for  the  attempted 
school  feeding  program  of  the  first  term  and  the  pro- 
visions made  for  our  open-air  classes,  it  will  be 
obvious  that  the  actual  school  programs  arranged 
for  our'several  groups  were  negligible  so  far  as  they 
afforded  opportunity  for  actual  food-taking,  rest, 
sleep,  fresh  air,  and  the  other  details  of  the  health 
regime.  Thus  any  results  from  our  procedure  were 
chiefly  secured  by  its  provision  of  a  sufficient  stimu- 
lus to  ensure  the  child's  cooperation  in  carrying  out 
the  prescribed  regime  at  home  and  elsewhere  in  the 
outside  environment.  That  this  is  the  real  function 
of  the  class  instruction  in  the  nutrition  program  is 
a  point  too  little  understood.  Indeed  the  subject 
matter  content  is  too  often  accepted  as  its  more 
obvious  raison  d'etre,  and  the  relative  value  of  class 
and  individual  instruction  is  sometimes  debated  by 
physicians  and  nutrition  workers,  who  fail  to  ap- 
preciate that  the  appeal  to  group  and  social  interests 


AN  EDUCATIONAL  PROGRAM  225 

afforded  by  the  class  sessions  is  what  determines 
their  importance  rather  than  their  informational 
character. 

The  appeal  of  the  class  session  rests  on  two  im- 
portant characteristics  of  the  child 's  psychology,  the 
desire  to  conform  to  group  standards  and  the  desire 
for  full  participation  in  the  activities  of  the  group. 
The  health  procedure  can  and  should  utilize  these 
native  desires  for  its  own  purposes.  Evidently  the 
disciplinary  difficulties  met  with  in  our  initial  pro- 
gram were  largely  due  to  disregard  of  them,  espe- 
cially to  failure  to  appreciate  the  child's  proper 
aversion  to  being  singled  out  as  different  from  his 
fellows.  So  far  as  our  later  programs  have  been 
successful  in  identifying  the  health  procedure  with 
recognized  group  standards  and  with  the  customary 
group  activities  of  the  class-room,  our  position  has 
been  correspondingly  strengthened.  We  can  appre- 
ciate, however,  that  a  health  program  recognized  by 
the  entire  school  would  have,  by  virtue  of  that  fact, 
greater  significance  for  the  enlistment  of  the  child's 
cooperation  than  a  program  limited  to  any  class  or 
several  classes  within  the  school.  That  the  socializa- 
tion of  the  class  procedure,  and  the  resulting  more 
active  participation  permitted  the  individual,  has 
played  its  part  in  securing  interest  and  increasing 
cooperation  in  our  two  later  programs,  will  also  be 
evident. 

Evaluation  of  success  and  failure  for  the  child 
must  he  measured  by  his  cooperation  and  by  in- 
dividual gain  in  fitness  rather  than  by  his  compara- 
tive gain  in  relation  to  that  of  his  fellows.  Atten- 
tion has  already  been  called  to  the  fact  that  the 


226  HEALTH  EDUCATION 

original  idea  of  stimulating  competition  between  the 
members  of  a  class  Avas  modified,  and  later  entirely 
discarded  by  ns,  wdth  no  loss  to  the  effectiveness  of 
our  procedure.  So  many  factors  enter  into  the  prob- 
lem of  health  that  failure  to  gain  or  to  keep  up  to 
standard  may  result  from  many  causes  over  which 
a  child  has  no  control.  On  the  other  hand,  he  may 
show  gains  by  reason  of  individual  endowment  while 
refusing  cooperation.  To  emphasize  failure  after  he 
has  cooperated  to  the  best  of  his  ability,  to  reward 
him  for  gaining  when  he  has  not  really  cooperated 
are  mistakes  as  unfortunate  from  the  educational  as 
from  the  moral  standpoint,  for  they  are  fatal  to  the 
continuance  of  interest  and  effort.  They  are,  how- 
ever, the  unavoidable  accompaniments  of  the  appeal 
to  competition.  The  situation  here  is  not  different 
from  that  attending  other  school  activities.  Unequal 
physical  endo^Mnent  is  on  a  par  with  unequal  mental 
endowment.  One  of  the  chief  dangers  of  the  appeal 
to  competition  is  its  possible  effect  on  the  children 
of  less  fortunate  endowment.  Among  individuals  of 
certain  nervous  organization  we  may  even  establish 
a  sense  of  inferiority  with  its  train  of  consequences, 
from  apparent  indifference  and  apathy  to  open  re- 
bellion and  misdemeanor.  The  seriously  retarded 
children  whose  presence  in  the  regular  school  grades 
is  so  universall}^  disturbing  to  discipline,  sufficiently 
illustrate  the  seriousness  of  this  problem.  Our 
health  procedure  must  not  be  allowed  to  increase  the 
number  of  irreconcilables  within  the  school.  It  must 
ensure  to  the  individual  the  satisfactions  and  re- 
wards of  his  endeavor. 

Again,  the  child  must  he  held  responsible  only  for 


AN  EDUCATIONAL  PROGRAM  227 

^^5  cooperation  in  such  activities  as  his  environment 
affords.    The  program  of  instruction  that  demands 
from  him  cooperation  he  is  unable  to  give,  or  fixes 
responsibility  on  him  for  environmental  conditions 
he  is  unable  to  control  will  not  succeed,  however  in- 
forming or  stimulating  to  action  it  may  be.     Our 
health  program  therefore  must  go  beyond  the  limits 
of  the  school  environment  and  the  school  day.     It 
must  make  a  consistent  attempt  to  secure  home  con- 
ditions that  permit  the  stimulus  of  the  class  pro- 
cedure to  function  in  the  activities  of  the  prescribed 
regime.    Thus  the  success  of  the  school  program  of 
health  education  is  dependent  on  a  serious  program 
of  education  in  the  community.     The  facts  of  our 
experience  amply  testify  to  the  dependence  of  suc- 
cess on  the  cooperation  of  the  home,  and  it  may  be 
well  to  consider  the  relative  position  of  the  school 
as  an  agency  for  securing  cooperation  of  this  kind. 
Where   a   corrective   procedure   is   undertaken   the 
school  is   doubtless  at  a   disadvantage  when  con- 
trasted with  the  hospital  clinic,  not  only  because  its 
opinion  in  matters  of  health  does  not  command  the 
same   deference,  but   from  the   additional  circum- 
stance that  the  parents  asking  assistance  from  the 
hospital  are  seeking  that  assistance  primarily  be- 
cause they  are  aware  of  the  child's  need.    They  are 
from  the  outset  prepared  to  accept  advice;  and  the 
same  is  true  of  the  parents  who,  by  seeking  the 
assistance  of  welfare  agencies,  acknowledge  their 
own  inability  to  supply  the  necessary  conditions  for 
the  family's  well-being.    When  the  school  enters  the 
field,  however,  it  must  assume  the  initiative ;  it  must 
be  the  first  to  apprise  many  parents  of  the  fact  that 


228  HEALTH  EDUCATION 

all  is  not  well.  The  first  intimation  that  the  child  is 
not  entirely  sound  may  be  the  visit  of  the  nutrition 
worker  and  the  request  for  the  stripped  examination 
by  a  physician  at  the  school.  Malnutrition  to  the 
parents  in  the  neighborhood  of  P.  S.  64  is  merely  the 
state  of  being  ''skinny"  and  if  any  relative,  near  or 
remote,  has  been  lank  or  simply  unusually  tall,  this 
fact  has  probably  been  a  sufficient  answer  to  any 
suspicion  that  a  child's  small  appetite  or  flabby 
muscles  might  indicate  ill  health.  Under  such  cir- 
cumstances we  must  expect  that  the  necessary  home 
cooperation  will  be  difficult  to  secure.  Indeed,  our 
experience  seems  to  show  that  it  cannot  be  secured 
without  a  campaign  of  patient  and  consistent  effort. 
Nor  is  this  all,  for  where  progress  is  slow  and  dis- 
couraging the  hospital  and  social  welfare  agency 
may  lose  the  patient.  Cases  that  do  not  respond, 
parents  that  refuse  cooperation,  inevitably  drop 
from  their  rolls,  but  such  is  not  true  of  the  public 
school.  The  chronic  case,  the  unadjusted  child,  the 
child  from  the  ill-regulated  home,  will  still  remain 
members  of  the  school  population ;  and  their  records 
will  inevitably  contribute  to  lowering  the  sum  total 
of  results  obtained. 

Our  experience  has  been  limited  to  the  demands 
of  a  corrective  procedure  but  it  will  be  evident  that 
an  extension  of  the  health  program  to  include 
normal  children  and  a  preventive  procedure,  must  be 
accompanied  by  a  corresponding  extension  of  the 
community  program.  Difficult  as  the  school  may 
find  it  to  enlist  the  cooperation  of  parents  whose 
children  are  normal,  whose  economic  circumstances 
are  independent  and  assured,  it  is  the  one  community 


AN  EDUCATIONAL  PROGRAM  229 

agency  that  can  attempt  to  do  so.  In  a  program  of 
health  education,  more  clearly  perhaps  than  in  any 
other,  the  futility  of  thinking  and  acting  by  different 
standards  becomes  apparent.  In  so  far  as  home 
standards  and  practices  remain  at  variance  with  the 
standards  for  health  habits  presented  by  the  school 
to  the  children,  appreciable  results  are  not  to  be  ex- 
pected. While  it  is  true  that  individual  children  in 
our  experience  succeeded  in  enlisting  for  themselves 
the  necessary  cooperation  from  their  parents,  and 
modifying  their  home  environment  to  some  extent 
in  accordance  with  the  ideals  of  our  health  teaching, 
such  cases  were  few  and  chiefly  confined  to  the 
children  of  superior  intelligence.  Unquestionably 
we  may  expect  that  a  degree  of  influence  will  be 
exerted  on  the  home  where  the  interest  of  the  chil- 
dren has  been  enlisted.  That  it  will,  unaided,  suffice 
to  achieve  definite  results  in  the  great  majority  of 
cases  appears  improbable,  and  from  the  larger  edu- 
cational viewpoint  undesirable  as  well.  Intelligent 
adult  control  of  the  environment  is  the  goal  to  be 
achieved,  not  dictation  to  the  adult  by  the  child.  The 
function  of  the  school  must  be  to  inform  and  enlist 
the  adults  of  the  home,  and  at  the  same  time  to  re- 
inforce intelligent  control  within  the  home,  through 
use  of  its  unequalled  opportunities  for  enlisting  the 
child's  cooperation. 

The  eificiency  of  the  health  program  will  be  ap- 
preciably increased  in  proportion  to  the  advan- 
tageous factors,  that  is  the  activities  and  conditions 
favorably  affecting  the  nutritional  processes,  pro- 
vided by  the  school  environment.  It  is  to  be  regret- 
ted that  our  series  of  experiments  cannot  furnish 


230  HEALTH  EDUCATION 

more  varied  and  convincing  examples  of  such  activi- 
ties and  conditions  and  of  their  influence  on  results. 
The  conditions  attending  the  mid-day  dinner  of  the 
first  experiment  prevented  our  realizing  appreciable 
gains  from  that  source.  There  is  some  probability, 
however,  that  the  mid-morning  lunches  served  dur- 
ing the  same  term  appreciably  increased  the  gains 
and  are  responsible  for  the  relatively  good  shomng 
made  by  our  first  classes  at  the  least  favorable  sea- 
son of  the  year  as  compared  with  that  of  the  fifth 
grade  children  during  the  same  season  a  year  later. 

The  contrast  between  the  results  achieved  by  the 
open-air  classes  during  the  fall  months  of  1918  and 
those  shown  by  the  fifth  grade  for  the  same  period 
is  the  best  example  our  records  afford  as  to  the  in- 
fluence of  factors  favorably  affecting  nutritional 
processes.  Optimum  conditions  of  ventilation,  sun- 
shine, facilities  for  rest  and  food-taking,  general  re- 
laxation of  the  usual  school  tension,  these  factors 
in  combination  appear  very  materially  to  have  in- 
creased the  gains  made  prior  to  the  onset  of  extreme 
cold  weather  and  the  season  of  minimal  increase. 
(See  Chart  A,  p.  84). 

But  the  value  of  advantageous  factors  for  the 
health  program  is  not  entirely  in  their  physical  ef- 
fect. Their  greater  educational  significance  must  be 
considered  as  well.  From  this  standpoint  they  are 
much  more  than  merely  corrective  or  palliative 
measures  and  we  may  well  claim  for  them  a  legiti- 
mate place  in  every  school  environment.  The  actual 
weight-getting  results  to  be  anticipated  from  the 
mid-morning  cup  of  milk  or  cocoa  for  example,  are 
relatively  negligible  as  compared  with  the  results  to 


AN  EDUCATIONAL  PROGRAM  231 

be  anticipated  from  cultivating  a  taste  for  them, 
especially  where  there  is,  in  addition,  an  understand- 
ing of  their  desirability  as  beverages  to  replace  tea 
and  coffee  in  the  home  dietary. 

Criteria  for  Educational  Experiences  in  the  Health 

Program 

If  we  analyze  the  activities  provided  in  the  pro- 
gram of  the  nutrition  class  we  will  appreciate  they 
are  of  two  types,  those  affording  the  child  experi- 
ences at  first  hand,  and  those  affording  informational 
experiences,  and  that  the  "advantageous  factors'* 
without  exception  provide  first  hand  experiences. 
Educational  tradition  however  is  so  largely  bound  to 
informational  experience,  that  it  is  only  with  diffi- 
culty the  school  can  be  brought  to  think  in  other 
terms  and  to  incorporate  activities  that  will  supply 
the  necessary  advantageous  factors  in  its  practice. 
The  weakness  of  the  school's  traditional  attack  on 
health,  as  embodied  in  the  text  book  of  hygiene,  the 
home  economics  course,  the  civics  syllabus,  the 
biology  syllabus,  or  in  such  socialized  group  activi- 
ties as  class  discussion,  story-telling  and  dramatiza- 
tion is  inherent  in  the  fact  that  the  health  experi- 
ences provided  by  these  activities  are  informational, 
and  the  habits  acquired  through  them  are  of  little 
or  no  value  as  directly  affecting  physical  condition. 
This  distinction  will  be  the  more  evident  if  we  con- 
trast the  procedure  employed  in  another  field  where 
health  is  also  the  objective  and  w^here  experience  at 
first  hand  is  frankly  accepted  as  the  sine  qua  non  of 
an  educational  program. 

Difficult  as  the  school  may  find  it  to  think  in  terms 


232  HEALTH  EDUCATION 

of  first  hand  experience,  the  department  of  physical 
training  must  of  necessity  ignore  any  other  kind, 
and  for  this  reason  its  procedure  affords  some  com- 
parisons of  value. 

While  a  considerable  body  of  subject  matter,  his- 
torical, social  and  physiological,  might  conceivably 
be  developed  in  connection  Avith  the  gymnasium  and 
playground  and  such  activities  as,  for  example,  ten- 
nis or  baseball,  no  attempt  is  made  to  use  such 
material  in  the  teaching  program,  nor  are  the 
hygienic  benefits  to  be  derived  from  participation 
discussed  in  class  more  than  incidentally.  The  great 
consideration  is  that  the  children  actually  partici- 
pate, use  the  exercises,  play  the  games,  enjoy  them, 
become  habituated  to  the  demands  they  make  on  the 
bodily  machinery  and  the  sensations  attending  them, 
and  come  finally  to  desire  these  for  their  own  sake. 
This  is  a  true  habit-forming  program.  The  advan- 
tageous factors  recognized  by  the  nutrition  class 
procedure  afford  corresponding  opportunities  for 
the  acquisition  of  habits  affecting  health,  and  thi^ 
is  the  objective  that  must  be  kept  before  us.  Al- 
though the  subject  matter  afforded  is  infinitely 
rich  and  important  to  society  such  claims  must  not 
confuse  us  as  to  the  secondary  place  to  be  accorded 
it  in  the  efficient  health  program. 

The  special  limitations  of  subject  matter  in  health 
education  must  be  recognized  before  a  just  estimate 
can  be  placed  on  the  value  of  dramatic  activities  and 
their  place  in  a  health  program.  Obviously  they 
provide  both  first  hand  and  second  hand  types  of 
experience.  It  will  be  easily  recognized  however 
that  although  a  certain  amount  of  bodily  activity 


AN  EDUCATIONAL  PROGRAM  233 

and  emotional  satisfaction  is  usually  incidental  to 
them,  such  first  hand  experiences  as  they  offer  fail 
to  supply  the  more  important  advantageous  factors. 
Thus,  however  desirable  the  opportunities  they  may 
afford  for  first  hand  experiences  in  social  education, 
manual  activities,  and  constructive  thinking,  their 
value  for  the  health  program  is  as  a  stimulus  to  the 
child's  cooperation,  and  lies  in  the  appeal  they  make 
to  group  interest  by  affording  participatory  ex- 
periences in  relation  to  informational  material. 

The  use  made  of  dramatization  in  our  series  of 
experiments  was  limited  to  the  class  activities  of  the 
first  grade  (1919-20).  It  consisted  in  such  recapitula- 
tions of  subject  matter,  previously  presented  in  story 
form,  as  the  children  could  organize  for  themselves. 
Thus  it  followed  the  recognized  educational  ideal  for 
dramatic  activities  at  this  age  period.  By  familiariz- 
ing the  little  child  with  subject  matter  under  con- 
ditions of  special  appeal  to  interest,  that  is  through 
participation  in  group  activities,  it  provided  an  ef- 
fective stimulus  to  cooperation.  In  developing  a 
procedure  for  the  older  classes  of  our  1918-19  pro- 
gram the  need  for  dramatic  activities  was  not  felt, 
as  the  socialized  class  discussions  apparently  offered 
sufficient  opportunity  for  participatory  experiences 
and  the  resulting  stimulus  to  interest.  Thus  a  dif- 
ference in  age  period,  and  the  resulting  difference 
between  play  level  and  work  level  activities,  very 
materially  affected  our  use  of  dramatization. 

The  greatest  use  of  subject  matter  was  made,  as 
has  been  described,  with  the  boys  of  the  fifth  grade 
class,  in  the  1918-19  program,  and  without  appre- 
ciable resulting  gains,  although  the  question  may 


234  HEALTH  EDUCATION 

legitimately  be  raised  whether  the  excellent  long 
term  results  sho^vn  by  this  group  may  not  have  been 
influenced  by  the  considerable  period  of  intensive 
instruction  given  them.  In  conceding  the  probability 
of  this,  the  importance  of  the  conditions  under  which 
the  instruction  was  given  must  be  urged.  In  addi- 
tion to  the  successful  enlistment  of  cooperation  from 
the  children  and  their  parents,  the  subject  matter 
used  was  closely  related  to  the  facts  of  a  daily 
regime  of  health  habits.  Imperfect  as  the  provisions 
for  this  regime  may  have  been,  either  within  the 
home  or  the  school  environment,  the  use  of  the  sub- 
ject matter  in  direct  relation  to  the  experiences  af- 
forded was  undoubtedly  vital  to  its  effective  func- 
tioning. To  reinforce  and  interpret  first-hand  ex- 
periences is  the  true  place  of  subject  matter  in  a  pro- 
gram where  health  habits  are  the  objectives.  It  is 
through  such  a  use  of  subject  matter  that  the  child's 
cooperation  becomes  informed  and  purposeful,  and 
his  attitude  toward  health  a  creative  one.  It  is  the 
weakness  of  the  home  that  it  too  often  insists  on  un- 
informed cooperation,  and  the  strength  of  the  school 
that  it  is  possessed  of  resources  capable  of  investing 
the  facts  of  hygiene  with  all  the  dignity  and  im- 
portance of  their  place  in  the  world  of  science.  In- 
deed, as  an  approach  to  the  study  of  science,  the 
subject  matter  involved  is  unsurpassed,  and  as  such 
its  development  and  use  by  the  school  is  greatly  to 
be  desired.  As  a  factor  in  the  health  program,  how- 
ever, it  is  easy  to  over-rate  the  place  it  should  occupy 
and  to  devote  to  it  time  and  resources  that  can  be 
more  effectively  employed,  if  our  criterion  is  to  be 
that  of  appreciable  results  in  phj^sical  well-being. 


AN  EDUCATIONAL  PROGRAM  235 

Implications  for  School  Procedure 

If  the  foregoing  interpretations  may  be  accepted 
as  offering  a  true  analysis  of  the  factors  determin- 
ing gains  in  our  series  of  experiments,  their  implica- 
tions for  practical  procedure  in  the  school  may  be 
grouped  under  the  following  recommendations : 

The  essential  features  of  the  nutrition  class 
procedure  should  be  incorporated  in  general 
school  practice,  and  the  resulting  health  pro- 
gram extended  to  all  children,  irrespective  of 
initial  physical  status. 

Closer  relationship  between  the  home  and  the 
school  in  matters  affecting  health  habits  should 
be  accomplished,  through  definite  provision  for 
community  enlightenment,  and  the  enlistment  of 
parental  cooperation. 

The  school  should  adjust  its  equipment  and 
procedure  to  afford  the  greatest  possible  num- 
ber of  ** advantageous  factors,"  and  undertake 
to  interpret  these  in  their  relation  to  a  compre- 
hensive program  of  personal  hygiene.  It  should 
supply  conditions  that  permit  the  development 
of  health  habits  because  of  the  environment 
rather  than  in  spite  of  it,  as  is  so  largely  the  case 
to-day. 

The  general  and  preventive  program  of 
health  education  should  be  supplemented  by 
special  provision  for  children  departing  from 
the  range  of  normal  variation  in  respect  to 
growth,  as  well  as  for  those  showing  indications 
of  disease,  infections,  or  the  usually  recognized 
physical  defects. 

SCOPE  OF  THE  PREVENTIVE  PROGRAM 

That  the  essential  features  of  the  nutrition  pro- 
gram may  be  profitably  extended  to  normal  children 


236  HEALTH  EDUCATION 

with  a  view  to  further  increasing  their  growth  and 
vigor,  appears  to  be  indicated  by  our  data  on  the 
comparative  weight  increase  of  children  of  varying 
degrees  'of  fitness,  under  an  improved  regime  sup- 
plemented by  instruction.  There  is  nothing  to  show 
that  children  of  standard  or  superior  fitness  may  not 
be  capable  of  corresponding  improvement  under 
similar  conditions.  Moreover  we  hardly  need  to 
emphasize  the  fact  that  important  as  growth  may  be 
in  providing  an  index  of  condition,  increased  physi- 
cal vigor  must  yield  additional  results  of  greater  or 
at  least  equal  importance.  Thus  whatever  the  limi- 
tations racial  and  family  status  may  impose  on  in- 
dividual development  in  height  and  weight,  the  pos- 
sibilities for  increasing  energy,  muscular  develop- 
ment and  endurance  are  not  correspondingly  limited. 
Health  education  based  on  the  needs  of  normal  chil- 
dren must  consider  such  results,  and  be  prepared 
to  evaluate  them  in  addition  to  those  in  growth. 

It  will  be  evident  that  our  nutrition  classes  gave 
only  passing  consideration  to  results  of  this  kind 
and  that,  through  them,  influence  was  continually 
exerted  to  prevent  over-exertion  and  emphasize  the 
need  of  rest,  rather  than  to  encourage  bodily  activity 
or  make  provision  for  muscular  development.  These 
limitations  were  imposed  by  the  conditions  at- 
tending a  corrective  program  for  underweight 
children.  Had  our  work  concerned  itself  with 
normal  children  the  contribution  of  the  playground 
and  gymnasium  must  have  been  included,  as  they 
provide  the  most  important '' advantageous  factors'* 
available  in  the  school  environment.  The  preventive 
health  program  must  definitely  relate  the  work  of 


AN  EDUCATIONAL  PROGRAM  237 

the  school  department  of  physical  training  to  a 
broader  plan  of  physical  education. 

Continuity. — The  scope  of  the  health  program 
in  regard  to  continuity  is  of  primary  importance 
if  results  of  lasting  value  are  to  be  secured. 
At  the  outset  our  program  had  for  its  object 
the  ''graduation"  of  the  children  enrolled,  as 
soon  as  they  should  attain  normal  weight  for 
height  and  age.  Administrative  considerations, 
however,  led  us  to  organize  our  classes  with 
reference  to  the  school  year  and  made  neces- 
sary the  retention  of  any  ''graduates"  for  the  fixed 
period  of  at  lea-st  a  term.  Observation  of  the  fluctua- 
tions shown  by  the  individual  charts  under  these 
conditions,  leads  to  the  conclusion  that  underweight 
children  "making  normal"  cannot  be  regarded  as 
definitely  "cured,"  and  therefore  to  be  at  once  dis- 
missed from  educational  influences.  On  the  contrary 
they  suggest  the  necessity  of  an  extended  period  of 
intensive  educational  influence,  and  the  desirability 
of  a  continuous  period  of  supervision.  It  is  probable 
that  a  health  program  organized  to  provide  con- 
tinuous environmental  influences  supplying  the 
necessary  "advantageous  factors,"  with  current 
evaluation  of  growth  and  physical  vigor,  will  func- 
tion to  the  best  advantage  when  combined  with  a 
period  of  intensive  educational  influence. 

Age  periods. — This  raises  the  question  as  to 
the  most  desirable  age  period  for  the  intensive 
program.  Our  work  was  chiefly  concerned  with 
children  in  the  pre-pubertal  stage  of  develop- 
ment or  at  the  age  of  school  entrance.  It  will 
be    obvious   that    both   periods    offer   advantages. 


238  HEALTH  EDUCATION 

With  the  younger  children  we  recognize  the  desir- 
ability of  intensive  work  at  a  period  when  habits, 
especially  dietary  habits,  are  still  fully  under  paren- 
tal control,  and  where  the  possibilities  of  home  co- 
operation are  correspondingly  increased.  Certain 
facts  of  growth  at  this  stage,  especially  those  con- 
cerned with  the  formation  of  the  permanent  teeth, 
argue  the  special  importance  of  intensive  educa- 
tional influence  during  the  first  year  or  two  after 
school  entrance.  From  the  standpoint  of  establish- 
ing a  creative  attitude  toward  health,  the  later  age 
period  probably  affords  better  opportunities  for 
educational  procedure.  Other  considerations  may  be 
urged  as  well.  The  great  increase  of  tuberculosis 
that  occurs  during  the  years  of  pubertal  change,  re- 
flects the  special  need  of  increased  physical  fitness 
at  this  age  period.  The  school,  by  supplying  inten- 
sive educational  influence  prior  to  this  period  of 
special  susceptibility,  could  in  a  very  special  sense 
offer  a  preventive  health  program.  While  our  study 
was  of  necessity  limited  to  children  below  the  high 
school,  it  T\all  be  apparent  that  certain  aspects  of 
health  education  can  best  be  developed  in  relation 
to  a  later  age  period  and  that  an  intensive  period 
of  educational  influence  is  especially  desirable  dur- 
ing one  of  the  years  of  high  school,  when  the  social 
and  civic  aspects  of  health  can  be  more  effectively 
related  to  the  facts  of  individual  development  and 
scientific  interest.  Consideration  of  each  age  period 
will  serve  to  establish  its  claim  to  special  provision 
and  lead  to  the  conclusion  that  our  health  teaching 
can  be  most  effectively  accomplished  by  definite  pro- 


AN   EDUCATIONAL  PROGRAM  239 

vision  in  the  school  curriculum  for  at  least  one  year 
of  intensive  work  at  each  of  these  age  periods,  pro- 
viding the  necessary  experiences  and  their  interpre- 
tation at  successive  educational  levels. 

The  Community  Program. — Consideration  of  the 
program  of  home  visiting  and  parents'  meetings 
developed  in  the  course  of  our  work  must  lead 
to  the  conclusion  that  any  suggestions  it  may 
afford  for  the  larger  program  of  health  edu- 
cation must  of  necessity  be  inadequate.  For  it 
will  be  evident  that  our  community  work  has  been 
limited  to  the  particular  needs  of  the  corrective  pro- 
gram, in  a  section  whose  homes  were  for  the  most 
part  ignorant,  and  little  above  the  low  water  mark 
of  economic  independence.  Thus  the  problems  met 
were  very  similar  to  those  usually  encountered  by 
the  social  service  workers  of  the  hospital  clinic  and 
welfare  agency,  and  the  solutions  offered  are  un- 
mistakably in  terms  of  relief  as  well  as  of  education. 
It  \d\\  be  evident  that  the  basic  questions  of  relation- 
ship between  home  and  school  are  effectually  be- 
fogged by  such  conditions.  Until  successful  demon- 
strations of  community  enlightenment  shall  have  been 
made  in  school  communities  where  education  and 
economic  independence  are  general  in  the  homes,  the 
true  character  and  scope  of  this  part  of  the  health 
education  program  mil  not  become  apparent.  We 
may  anticipate,  however,  that  qualities  of  leadership 
are  necessary,  and  a  democratic  rather  than  a 
benevolent  attitude.  Initiative,  social  vision,  knowl- 
edge of  both  school  and  community  resources,  and 
ability  to  organize  them,  these  probably  are  de- 


240  HEALTH  EDUCATION 

manded  rather  than  the  more  specific  techniques  and 
special  types  of  training  now  identified  with  the  cor- 
rective procedure. 

A  few  evident  facts  of  our  experience  are  of 
special  significance  in  relation  to  any  community 
program.  First  among  them  we  may  mention  the 
necessary  time  element  involved,  and  the  lack  of 
anything  spectacular  in  the  results  accomplished. 
These  two  characteristics  argue  the  educational 
health  procedure  ill-adapted  to  purposes  of  propa- 
ganda, if  by  propaganda  we  mean  a  demonstration 
necessitating  early  and  spectacular  results.  Thus 
attempts  to  enlist  community  interest  through  the 
organization  of  demonstration  classes,  are  hardly 
calculated  to  achieve  success.  Initial  propaganda 
should  preferably  take  other  forms  and  be  followed 
by  the  health  program  or  the  nutrition  class.  On 
the  other  hand  the  whole  testimony  of  our  experience 
points  to  the  possibilities  for  community  enlighten- 
ment attending  a  consistent  and  long  continued  dem- 
onstration of  the  educational  procedure. 

That  general  educational  principles  apply  to  the 
adult  and  community  program,  as  well  as  to  the  pro- 
visions made  for  the  children  may  also  be  urged, 
and  thus  we  may  expect  informational  experiences 
to  function  in  proportion  to  their  association  with 
experience  at  first  hand.  For  this  reason  the  records 
offered  by  the  weiglit  charts  and  the  discussion  of 
them  in  the  parents'  meetings  offer  certain  sugges- 
tions as  to  methods  applicable  to  a  general  com- 
munity program. 

Our  experience  in  connection  wdth  reports  made 
by  the  children  as  to  details  of  the  home  regime 


AN   EDUCATIONAL  PROGRAM  241 

emphasizes  the  necessity  of  accuracy  in  such  reports, 
and  the  difficulty  of  securing  it  unless  very  definite 
provision  for  verification  through  home  visiting  and 
parental  cooperation  can  b(>  made.  Even  so  there  is 
much  opportunity  for  error,  many  parents  being  as 
inaccurate  as  the  children  in  regard  to  specific  de- 
tails. Moreover  the  additional  expense  and  labor 
attending  such  verification  makes  it  prohibitive  un- 
less undertaken  as  in  our  experiments,  for  special 
classes  and  for  children  needing  a  corrective  pro- 
gram. Under  the  circumstances  any  system  of  re- 
wards or  credits  based  only  on  reports  from  the 
children  appears  distinctly  undesirable,  and  to  be 
avoided  as  placing  a  premium  on  inaccuracy,  and 
very  possibly  on  hypocrisy.  It  would  seem  that 
effective  relationship  between  community  and  school 
in  the  health  program  must  be  developed  along  other 
lines. 

Adjustments  within  the  School. — Within  the 
school  the  health  program  demands  provision  for 
continuous  supervision  and  record-keeping  for  every 
child,  provision  for  the  greatest  possible  number  of 
advantageous  factors  within  the  school  environment, 
provision  for  enlisting  the  intelligent  cooperation  of 
all  children  in  respect  to  advantageous  factors  both 
at  home  and  in  school. 

To  effect  a  continuous  supervision  of  individual 
condition  in  regard  to  health,  the  best  available 
provisions  for  physical  examinations  and  medi- 
cal inspection  should  be  supplemented  by  fre- 
quent records  of  height  and  weight.  In  addi- 
tion to  its  importance  as  a  record  from  which  cur- 
rent   results    may    be    evaluated,    the    individual 


242  HEALTH  EDUCATION 

growth  chart  is  a  device  of  undoubted  educational 
value.  It  presents  a  graphic  record  of  facts  to  be 
interpreted  by  relating  the  child's  experiences  at 
first  hand  directly  to  the  necessary  informational 
material.  As  a  means  of  enlisting  interest  and  hold- 
ing it,  it  is  without  doubt  the  best  device  we  have, 
and  the  only  one  of  its  kind.  Like  all  other  devices 
in  educational  procedure,  it  is  susceptible  of  misuse. 
The  successive  modifications  adopted  by  us  in  regard 
to  its  use  reflect  the  more  serious  possibilities  of  this 
kind.*  Weight  and  height  measurements  present 
many  opportunities  for  inaccuracy  and  the  keeping 
of  the  current  records  must  be  in  the  hands  of  care- 
ful and  experienced  adults,  if  they  are  really  to  ful- 
fill their  function  in  affording  the  necessary  data 
for  evaluating  the  health  procedure.  For  this 
reason  the  responsibility  for  taking  measurements 
cannot  be  relegated  to  the  children  themselves  and 
undertaken  as  a  class  activity,  excellent  as  such  an 
experience  might  be  from  the  educational  standpoint. 
It  is  a  question  how  far  the  class  teacher  may  be 
relied  on  for  such  measurements.  In  our  work  all 
measurements  and  records  were  made  by  the  nutri- 
tion workers  who  had  been  carefully  instructed  as  to 
methods.  Under  the  supervision  of  trained  workers 
the  experiences  incidental  to  height  and  weight  tak- 
ing may  well  be  made  to  yield  their  quota  of  par- 
ticipatory activities  for  the  children.  The  conditions 
obtaining  in  the  eye  clinic  room  a  P.  S.  64,  how- 
ever, effectually  prevented  the  development  of  the 
educational  possibilities  the  measurements  should 
have  afforded,  beyond  informal  discussion  with  the 

•  See  Appendix  C. 


AN  EDUCATIONAL  PROGRAM  243 

child  of  his  own  gains  or  losses  in  relation  to  his 
daily  regime. 

The  provision  of  advantageous  factors  within  the 
school  environment  should  be  such  as  to  supply  con- 
tinuous experiences  that  will  be  health  building  and 
habit-forming.  How  can  this  be  accomplished? 
Obviously  the  school's  function  in  regard  to  facilities 
for  feeding,  sleeping  and  bathing  must  always  be 
limited.  Whatever  provision  it  may  make  in  these 
directions  must  be  of  value  rather  as  they  afford 
suggestions  for  the  home  or  supplement  its  provi- 
sions. The  conditions  obtaining  in  the  average 
homes  of  any  school  community  must  determine  the 
relative  need  for  such  experiences  and,  to  an  extent, 
the  method  of  supplying  them. 

Thus  the  comparative  failure  of  the  mid-day 
luncheon  to  function  in  the  program  of  P.  S.  64  is 
inconclusive  as  to  its  possible  advantages  in  a  dif- 
ferent community.  Properly  conceived  and  executed, 
the  school  lunch  could  be  made  an  ideal  educational 
vehicle.  Examples  of  a  carefully  planned  lunch- 
room service  may  be  found  in  several  of  our  welfare 
agencies,  combining  a  program  of  full  feeding,  with 
opportunity  for  the  broadening  of  dietary  habits, 
and  the  inculcating  of  healthful  table  habits.  It  is, 
however,  a  long  step  from  the  commercially  con- 
ducted lunch-rooms  of  our  city  schools  to  the  educa- 
tional ideal. 

The  difificulties  concerning  the  administration  of 
the  school  lunch  are,  indeed,  so  many,  that  it  is  a 
serious  question  how  far  it  can  be  considered  a  prac- 
tical undertaking  if  carried  out  in  the  ideal  way, 
which  involves  not  only  the  careful  selection  and 


244  HEALTH  EDUCATION 

preparation  of  the  food  supplied,  but  also  the  super- 
vision of  the  children  in  their  selection  of  food  and 
eating  habits.  The  noise  and  confusion  generally 
found  in  the  school  lunch-room,  the  haste  that  so 
often  prevails,  are  questionable  attendants  to  a  satis- 
factory meal.  It  is  only  too  evident  that  our  large 
public  schools  cannot  provide  a  substitute  for  the 
home  in  these  particulars,  although  much  can  be  done 
to  improve  the  conditions  usually  found,  if  the  value 
of  serenity  and  of  desirable  eating  habits  can  be 
fully  established  in  the  minds  of  the  teaching  staff. 
The  results  claimed  for  improvement  in  the  condi- 
tion of  the  children  where  the  usual  system  prevails, 
and  the  luncheon  is  served  on  the  cafeteria  plan,  with 
the  stipulation  that  one  essential  dish,  generally  a 
thick  soup  with  bread  and  butter,  must  be  purchased 
by  every  child  before  he  can  secure  sweets,  cannot  be 
said  to  establish  the  value  of  the  school  lunch  as  an 
educational  factor  nor  even  as  a  health-making  fac- 
tor, the  inference  to  be  draA\Ti  is  rather  against  the 
unsatisfactory  conditions  obtaining  in  the  average 
home  of  the  community  concerned. 

The  desirability  of  the  mid-session  luncheon  of 
milk  or  cocoa  as  an  educational  experience  seems 
evident  aside  from  the  probable  existence  in  any 
school  population,  of  children  whose  breakfast  has 
been  inadequate.*  When  it  is  recalled  that  much  of 
the  difficulty  over  the  eating  of  breakfast,  and  of  the 
hurried  conditions  attending  luncheon  in  many  homes 
as  well,  is  directly  related  to  the  penalties  imposed 
by  the  school  on  late-comers,  the  desirability  of  better 
adjustment  between  the  schedules  of  the  school  and 

*  Sec  Appendix  D. 


AN  EDUCATIONAL  PROGRAM  245 

home  with  relation  to  this  particular  point  suggests 
itself.  Lengthening  of  the  noon  hour  to  include  a 
rest  period  at  home  for  the  younger  children  would 
probably  be  attended  in  many  communities  with  bet- 
ter results  than  we  were  able  to  secure  at  P.  S.  64. 

Except  for  the  special  provisions  at  Christodora 
House  during  our  first  term  and  in  the  open-air 
classes,  the  conditions  we  were  able  to  provide  with 
regard  to  rest  periods  were  really  little  better  than 
those  attending  dramatic  experiences.  As  such  they 
served  a  purpose  but  their  functioning  as  true 
advantageous  factors  is  to  be  questioned. 

The  possibilities  and  responsibilities  of  the  school 
in  regard  to  the  advantageous  factors  related  to 
bodily  activity,  habits  with  respect  to  ventilation, 
and  emotional  attitudes,  are  probably  of  greater 
importance  to  health  than  those  attending  any 
routine  experiences  it  may  supply  as  to  food  and 
rest.  Indeed  we  cannot  properly  estimate  the 
part  these  might  play  in  the  establishment  of 
health  habits  and  increased  vigor,  unless  we  first 
conceive  of  a  school  environment  successfully 
affording  optimum  conditions  in  regard  to  each, 
continuously  throughout  the  school  day,  the  school 
year,  and  the  years  of  school  attendance.  If  the 
total  influence  to  be  exerted  appears  a  fairly  con- 
siderable one  viewed  in  this  perspective,  what  is  to 
be  said  for  the  present  general  adherence  to  seden- 
tary traditions,  questionable  winter  atmospheres, 
and  frequency  of  nervous  tension  and  worry  in  our 
school-rooms?  Unfortunately  science  has  not  yet 
spoken  on  these  matters  with  sufficient  definiteness 
to  make  her  message  to  the  school  an  unmistakable 


246  HEALTH  EDUCATION 

one.  Comparable  experiments  carefully  planned 
with  a  view  to  ascertaining  comparative  results  in 
gro'wi:h  under  differing  school  environments  are  evi- 
dently needed  before  general  progress  in  these 
directions  can  be  expected.* 

Provision  for  enlistment  of  the  children's  coopera- 
tion with  regard  to  advantageous  factors  must  in 
the  last  analysis  depend  on  the  attitude  of  the 
school's  teaching  staff,  and  especially  on  the  class 
teacher's  appreciation  of  their  essential  values  for 
health,  and  of  their  scientific  and  social  interest. 
Constant  contact  with  an  adult  whose  o^^^l  attitude 
tow^ard  health  is  informed  and  creative,  must  ever  be 
the  most  potent  of  influences  the  school  can  bring  to 
bear  on  the  development  of  a  health  program,  and  of 
a  tradition  of  health  within  the  school.  Under  such 
influence  the  facts  of  daily  environment  and  routine 
deliver  their  true  message,  and  are  raised  to  their 
true  dignity. 

So  far  as  the  experiences  offered  by  advantageous 
factors  lead  on  to  wider  fields  of  interest,  an  educa- 
tional program  of  very  special  value  may  be  de- 
veloped, although  it  may  have  little  increased  signifi- 
cance as  a  health  program.  The  more  modern  types 
of  school  curricula  where  subject  matter  is  definitely 
organized  about  the  child's  natural  interest  in  food, 
shelter,  and  clothing,  thus  present  special  possibili- 
ties for  supplementing  the  health  program  and  will 
in  turn  be  reinforced  by  it.f 

*  See  Appendix  D — where  an  experiment  of  the  kind  is  outlined. 

t  For  illustration  see  Goodlander,  Mabel  B.,  Education  through 
Experience,  Bui.  No.  X,  Bureau  of  Educational  Experiments,  1921 — 
where  a  number  of  class  projects  in  food  study  (fourth  grade)  are 
described. 


AN   EDUCATIONAL  PROGRAM  247 

This  will  be  especially  true  of  those  age  periods 
chosen  for  the  more  intensive  health  programs. 
Food  experiences  offered  by  the  school  can  probably 
be  provided  to  the  best  advantage  in  connection  with 
such  programs.  When  necessary  adjustments  can 
be  made  to  permit  such  first-hand  experiences  as  the 
selection,  purchase,  preparation  and  serving  of  food 
by  the  children  themselves,  the  informational  con- 
tent incidental  to  such  activities  will  greatly  enrich 
the  experience  and  the  children's  cooperation  will  be 
easily  enlisted.  Such  activities  should  be  organized 
from  a  viewpoint  somewhat  different  from  that 
usually  held  by  the  Domestic  Science  Department,  in 
that  the  specific  object  should  be,  not  so  much  the 
technique  of  cookery,  as  the  study  of  foods,  their 
values  and  place  in  the  dietary. 

The  content  of  such  a  series  of  lessons  should  be 
determined  principally  by  the  recognized  need  for 
broadening  the  dietary  of  the  young  child,  and  there- 
fore the  emphasis  should  be  placed  chiefly  on  fresh 
vegetables,  cereals,  milk  dishes  and  eggs,  as  the  types 
of  foods  with  which  the  home  generally  experi- 
ences the  greatest  difficulty  in  establishing  satisfac- 
tory dietary  habits.  Simple  equipment  and  simple 
methods  of  preparation  are  all  that  should  be  con- 
sidered in  such  a  course  of  instruction  for  elemen- 
tary grade  children.  A  most  important  factor  how- 
ever is  the  provision  of  opportunity  for  the  class  to 
serve  and  eat  their  dishes,  and  thus  secure  the  effects 
of  the  group  appeal  in  acquiring  a  taste  for  new 
foods.  In  connection  with  such  experiences  we  must 
appreciate  that  the  program  that  educates  to  the 
importance  of  caloric  intake,  ivithout  special  em- 


248  HEALTH  EDUCATION 

pJiasis  on  conceptions  of  balanced  feeding  and  vita- 
mine  intake,  is  inadequate. 

Our  initial  program  for  diet  and  school  feeding 
especially  emphasized  the  importance  of  caloric  in- 
take and  in  this  followed  the  general  lines  prescribed 
by  Dr.  Emerson.  Insistence  on  the  elimination  of 
tea  and  coffee,  and  on  milk  as  an  essential  of  the 
child's  dietary,  however,  adds  to  his  program  some 
additional  elements  of  importance,  and  the  emphasis 
on  cereal  foods  is  a  particularly  practical  method  of 
supplementing  the  dietary  with  inexpensive  carbo- 
hydrate foods,  with  the  least  possible  danger  to 
interference  with  the  family  budget  and  customary 
menu.  Our  experience  seems  to  indicate  the  insuffi- 
ciency of  this  simple  program,  for  a  community  of 
the  kind  in  w^hicli  we  were  working.  Acquaintance 
v/ith  the  dietaries  of  the  homes  shows  lack  of  knowl- 
edge as  to  balanced  diet,  lack  of  knowledge  as  to 
vitamines,  their  place  and  importance,  as  to  fats  and 
the  ability  of  young  children  to  digest  them,  as  to 
the  peculiar  properties  of  milk,  and  as  to  the  undesir- 
ability  of  condiments  especially  in  the  diet  of  the 
child.  Incomplete  as  present  knowledge  in  regard  to 
food  properties  must  be  admitted  to  be,  very  con- 
siderable progress  in  this  field  of  science  has  been 
made  in  recent  years,  and  any  program  of  health 
undertaken  in  the  school  must  take  cognizance  at 
least  of  the  best  authenticated  facts  of  recent  labora- 
tory experiment. 

THE  CORRECTrVTE  PROGRAM 

While  the  true  starting  point  for  an  educational 
procedure  is  the  development  of  the  general  health 


AN   EDUCATIONAL  PROGRAM  249 

program  with  prevention  as  its  aim,  the  school  can- 
not ignore  those  children  whose  physical  condition 
indicates  the  need  of  corrective  measures  and  special 
care.  For  them  a  corrective  program  supplemen- 
tary to  the  general  program  must  be  arranged,  but 
many  of  its  details  and  provisions  Avill  of  necessity 
vary  with  the  varying  conditions  offered  by  the 
homes  of  the  school  community,  and  the  adequacy  of 
the  health  provisions  incorporated  by  the  school  in 
its  preventive  program.  In  general  we  must  antici- 
pate that  special  provisions  affording  advantageous 
factors  ivill  he  a  necessary  part  of  the  corrective 
program  inversely  to  the  proportion  in  which  the 
home  and  school  environments  afford  them.  There 
are  still  many  questions  to  be  answered,  however,  as 
to  the  relative  value  of  differing  provisions  especi- 
ally those  relating  to  food  intake  and  air,  before  our 
use  of  advantageous  factors  can  become  scientific 
and  correspondingly  efficient.  Further  experiment 
is  needed  to  establish  the  place  and  character  of  the 
school  lunch  in  the  corrective  program,  and  special 
research  as  to  the  effect  of  varying  conditions  of 
temperature  and  ventilation  on  the  nutritional  proc- 
esses and  growth,  must  determine  the  place  of  the 
open-air  class  and  the  open-window  room.* 

Whatever  the  special  needs  of  a  given  community, 
the  essential  provisions  of  the  corrective  program 
must  concern  the  extension  of  the  school  medical  ser- 
vice to  provide  special  examination,  diagnosis,  and 
observation,  for  children  whose  nutritional  status  is 
in  question,  as  well  as  for  those  presenting  obvious 
defects  or  symptoms  of  infections  and  diseases.     In 

*  See  Appendix  D. 


250  HEALTH   EDUCATION 

addition  to  underweight  for  height  and  age,  over- 
weight for  height  and  underheight  for  age  must  be 
included  in  our  conception  of  defective  nutritional 
status  if  the  program  is  to  be  in  any  sense  complete. 
The  first  function  of  the  school  medical  staff,  then, 
will  be  to  determine  cases  needing  special  physical 
care,  improved  regime  or  medical  treatment,  and  to 
inform  the  home  of  its  findings.  Where  the  home 
cannot  supply  the  necessary  medical  care,  the  school 
medical  staff  must  be  prepared  to  assume  the  re- 
sponsibility for  arrangements  with  the  various  hos- 
pital and  other  agencies  in  the  community,  as  was 
so  generally  done  at  P.  S.  64.  Here  again  the 
character  of  the  community  must  largely  determine 
the  actual  relationships  to  be  established. 

THE    STAFF 

When  we  review  the  foregoing  implications  for 
school  procedure  with  the  necessary  members  and 
personnel  of  an  adequate  staff  in  mind,  the  following 
conclusions  force  themselves  to  attention: 

The  positive  health  program  demands  a  con- 
siderably increased  school  staff. 

Its  success  must  depend  on  a  personnel  capa- 
ble of  coordinating  the  requisite  knowledge  and 
techniques  from  several  professional  fields. 

The  relative  importance  of  special  types  of 
technical  training  Avill  not  be  the  same  for  the 
preventive  as  for  the  corrective  program. 

Numbers. — It  will  be  realized  that  at  P.  S.  64 
our  staff  were  entirely  concerned  with  problems 
of  corrective  work,  and  our  experiment  amply  testi- 
fies to  the  size  of  the  corrective  program  in  that 
school    community.      The    work,    as    reported,    in- 


AN   EDUCATIONAL  PROGRAM  251 

eluding  physical  examinations,  weekly  measure- 
ments, individual  and  class  instruction,  home 
visiting  and  parents'  meetings,  and  arrangements 
for  cases  needing  special  consultations,  examina- 
tions or  treatment  of  defects,  with,  in  addition, 
the  measurements  of  the  control  groups,  consti- 
tuted a  really  arduous  program  for  our  nutri- 
tion workers,  who  were  able  to  care  for  an  average 
of  but  40  children  each,  and  who  felt  keenly  the  need 
of  more  extensive  provisions  for  medical  care 
throughout  the  experiment.  Moreover,  the  de- 
mands on  the  physician's  time  were  relatively  in- 
creased. Because  of  the  diversity  and  importance 
of  the  causal  factors  underlying  malnutrition,  diag- 
nosis of  the  condition  requires  care  and  experience 
on  the  physician's  part.  Thus,  in  any  adequate  plan 
for  a  corrective  procedure,  physical  examinations  ar- 
ranged for  the  children  found  to  be  underweight  must 
be  given  a  longer  time  allowance  than  is  customarily 
provided  in  schools,  and  the  number  of  under- 
weights that  can  profitably  be  examined  in  succession 
is  limited  by  the  tendency  for  the  procedure  to  be- 
come a  mere  routine,  where  one  child  after  another 
presents  no  clearly  defined  symptoms  beyond  those 
of  poor  general  condition.  Six  or  eight  under- 
weights probably  represent  as  many  cases  of  this 
kind  as  one  physician  can  profitably  undertake  to 
diagnose  in  succession.  Beyond  the  mere  statement 
that  an  increased  personnel  is  required,  however,  it 
is  hard  to  draw  just  inferences  as  to  the  probable 
number  of  workers  needed  in  a  different  adminis- 
trative situation,  where  the  corrective  program  is 
in  the  hands  of  the  regular  school  medical  staff  and 


252  HEALTH  EDUCATION 

is  supplementary  to  an  adequate  preventive  pro- 
gram. It  will  be  evident,  too,  that  the  initiation  of 
any  health  program  will  inevitably  demand  more 
time  and  effort  than  should  be  necessary  subse- 
quently. After  physical  defects  have  been  largely 
corrected,  parental  cooperation  established,  and 
community  understanding  secured,  the  proportions 
of  the  program  will  be  correspondingly  reduced. 

We  may  conclude  from  our  experience,  however, 
that  unless  an  adequate  staff  is  provided  for  the  cor- 
rective program,  its  demands  ^\all  absorb  the  atten- 
tion of  the  workers,  and  overshadow  the  claims  of 
the  preventive  program.  Thus,  although  our  pro- 
visions for  health  should  start  with  those  for  pre- 
ventive work,  practically,  the  existing  need  for  cor- 
rective work  must  always  be  supplied  before  the 
time  and  thought  of  the  workers  engaged  can  be 
given  to  very  much  else,  and  our  personnel  there- 
fore must  be  definitely  planned  to  cover  the  correct- 
ive work  in  addition  to  the  general  program. 

Personnel. — The  principal  techniques  employed 
in  the  nutrition  class  are  those  of  the  physician  and 
nurse,  of  the  social  case  worker,  and  of  the  teacher. 
While  the  contributions  of  other  technically  trained 
workers  are  also  essential,  success  in  the  main  de- 
pends on  provisions  for  the  combined  medical, 
sociological  and  educational  attack,  and  the  organi- 
zation of  the  work  to  permit  the  most  effective  con- 
tribution from  workers  in  each  of  these  fields.  If 
we  analyze  the  chief  provisions  of  both  the  cor- 
rective and  preventive  programs,  we  will  find  these 
techniques  represented  with  somewhat  differing 
emphasis. 


AN   EDUCATIONAL   PROGRAM  253 

The  preventive  program  must  provide  for  (1)  or- 
ganization of  the  school's  resources  for  health;  in 
respect  to  physical  examinations  and  record-keep- 
ing ;  environmental  conditions  and  equipment ;  effect- 
ive cooperation  of  the  class  teachers  and  of  special 
teachers,  especially  in  the  departments  of  physical 
training,  of  home  economics,  and  science;  (2)  en- 
listment of  the  community  and  cooperation  of  the 
homes,  through  publicity,  adult  education,  parent- 
teacher  programs,  and  organization  of  the  forces 
influencing  public  opinion. 

The  corrective  program  must  provide  for  (1)  spe- 
cial examination,  observation  and  diagnosis,  with 
individual  instruction  and  advice,  for  children  whose 
physical  examination  indicates  specific  problems  or 
lowered  general  condition;  (2)  individual  follow- 
up  to  secure  special  provisions  for  care  from  the 
family  physician  or  hospital  agency,  in  the  homes 
and  at  school. 

That  is,  the  preventive  program  is  primarily  a 
teacher's  program,  dependent  on  physiological 
knowledge  and  the  physician's  advice  to  be  sure, 
but  essentially  concerned  with  problems  of  school 
organization  and  teaching  techniques,  and  with  a 
supplementary  program  of  adult  education  that  calls 
for  community  social  work  rather  than  for  social 
case  work.  It  is  evident  that  professional  and  tech- 
nical qualifications  for  corrective  work  will  not  in 
themselves  constitute  the  necessary  qualifications 
for  the  personnel  of  the  school's  general  health  pro- 
gram, and  the  subtle  differences  of  temperament,  in- 
terests, and  attitudes  that  characterize  the  worker  in 
the  medical  field,  in  sociology,  and  in  education,  must 


254  HEALTH  EDUCATION 

be  considered  in  addition  to  any  practicum  for  train- 
ing.    The  starting  point  of  interest  for  the  physician 
and  nurse  is,  in  the  great  majority  of  cases,  ill- 
health.  Pathology  rather  than  hygiene  absorbs  their 
attention,  and  similarly,  the  interest  of  the  sociolo- 
gist is,  for  the  most  part,  centered  on  poverty  and 
its  problems.     At  the  same  time  the  physician,  the 
nurse,  the  case  worker,  as  a  rule,  have  but  little 
understanding  of  recent  developments  in  education- 
al techniques,  and,  like  most  of  the  community,  base 
their  conceptions  of  acceptable  procedures  on  the 
experiences  of  their  own  school  days,  15,  20,  30  years 
ago  as  the  case  may  be.     The  modern  teacher  has 
some  very  good  grounds  for  instinctive  reservations 
toward  the  "educational  programs"  suggested  by 
outside  enthusiasts,  whose  ideas  of  teaching  in  nine 
cases  out  of  ten  will  be  found  to  consist  in  the  di- 
dactic  presentation    of   additional   subject   matter. 
Physicians  in  particular  seem,  as  a  profession,  to 
lack  the  necessary  attitude  for  teaching  children, 
possibly  because  their  consciousness  of  the  great 
body  of  subject  matter  incident  to  their  own  pro- 
fessional training  renders  them  especially  suscept- 
ible to  the  temptations  of  didacticism  as  a  "short 
cut"  to  knowledge.     Our  nutrition  class  for  the  first 
term  clearly  showed  the  educational  limitations  and 
fallacies  incident  to  a  school  procedure  in  the  hands 
of  specialists  untrained  in  educational  techniques. 
It  seems  evident  that  our  positive  health  program 
must  be  entrusted  to  a  new  type  of  worker  who  shall 
be  at  once  ahygienist  and  a  teacher,  who  shall  as  such 
cooperate  mth  the  teaching  staff  on  the  one  hand, 
and  with  the  medical  staff  on  the  other,  supplement- 


AN  EDUCATIONAL  PROGRAM  255 

ing  each  without  superseding  either.  The  advisa- 
bility of  freeing  such  a  worker  entirely  from  respon- 
sibility for  corrective  measures,  and  thus  ensuring 
individual  effort  and  attention  for  the  development 
of  a  constructive  health  program  will  be  evident. 
The  organization  of  the  school's  total  resources  for 
health,  and  the  resulting  modifications  in  the  exper- 
iences afforded  to  all  children,  should  relieve  the 
corrective  program  from  the  necessity  for  class  in- 
struction, and  modify  the  requisite  qualifications 
for  its  personnel  accordingly. 

If  the  preventive  program  is  primarily  a  teacher's 
jjrogram,  the  corrective  program,  on  the  other  hand, 
is  primarily  the  physician's  and  should  be  directed 
by  him.  The  great  variety  of  the  causal  factors  in- 
volved and  the  serious  nature  of  many  of  them  argue 
the  importance  of  the  physician's  services  here,  and 
the  danger  of  entrusting  the  responsibility  for  diag- 
nosis, or  advice  as  to  remedial  measures,  to  any 
worker  of  narrower  experience  or  less  thorough 
training. 

It  will  be  evident  that  the  services  of  the  visit- 
ing case  worker  are  necessary,  to  supplement 
the  work  of  the  physician  and  school  nurse,  and  that 
the  demands  of  the  situation  offer  a  distinct  status 
for  a  medical  social  worker.  In  a  community  like 
that  of  P.  S.  64,  a  dietitian's  training  is  of  undoubted 
advantage  for  the  home  visitor.  Success,  however, 
is  primarily  dependent  on  the  case  worker's  attitude 
and  technique,  and  in  such  a  community  the  dieti- 
tian without  these  can  hardly  be  expected  to  succeed. 
The  place  of  the  case  worker  and  dietitian  in  school 
communities  where  better  economic  conditions  ob- 


256  HEALTH  EDUCATION 

tain  has  yet  to  be  defined,  but  development  of  the 
school  health  program  in  such  communities  will 
probably  modify  our  present  conceptions  as  to  the 
scope  of  such  work,  and  the  necessary  qualifications 
and  training  of  the  worker. 

Summary 

The  health  program  that  shapes  itself  from  the 
foregoing  interpretations  must  not  discourage  by 
reason  of  its  proportions.  It  should  lead  rather  to 
a  new  realization  that  "public  health  is  purchas- 
able," and  that  the  purchase  price  must  include  as 
always  initiative,  ability,  and  continued  conscien- 
tious effort.  So  far  as  the  experiment  at  P.  S.  64 
has  broken  ground  by  uncovering  problems  and  pos- 
sibilities, we  believe  its  record  will  prove  service- 
able to  the  cause  of  public  health  and  public  educa- 
tion. The  chief  points  in  our  thinking  to-day  as  we 
bring  this  study  to  a  close  may  be  briefly  summar- 
ized as  follows : 

The  efficient  program  of  health  education  must 
recognize  the  primary  importance  of  nutritional 
status  as  a  basis  for  estimating  general  physical 
condition  among  children.  Such  recognition  in- 
volves a  considerable  program  of  scientific  research, 
community  enlightenment  and  school  adjustment. 

Results  of  the  health  program  should  he  evaluated 
currently  through  individual  records  of  groivth  in- 
crement and  nutritional  status.  Not  merely  pre- 
vention of  lowered  phj^sical  condition  and  approxi- 
mation to  currently  accepted  "norms"  should  be  the 
aim,  but  physical  vigor  and  height  and  weight  in- 


AN  EDUCATIONAL  PROGRAM  257 

crease  in  excess  of  our  present  standards  for  race 
and  stock. 

The  resources  of  the  school  for  supplying  the 
chief  provisions  essential  to  the  success  of  an  educa- 
tional health  program  are  greatly  superior  to 
those  at  the  command  of  any  other  agency.  Great 
as  the  initial  task  may  be,  the  school  can  eventu- 
ally transmit  the  necessary  conceptions  to  the 
community  and  enlist  the  cooperation  of  both  child 
and  home,  and  it  is  the  only  agency  organized  to 
reach  every  child  and  every  home.  It  is  the  only 
agency,  therefore,  that  can  advantageously  secure 
the  data  necessary  for  research  from  all  sections  of 
the  community,  and  present  a  true  cross-section  of 
child  development  from  every  type  of  home,  and 
from  adequate  numbers  of  well  children,  of  differing 
racial  strains  and  differing  economic  levels. 

The  preventive  program  of  health  education  must 
he  basic,  an  integral  part  of  the  school's  general 
thinking,  administration  and  equipment.  It  cannot 
be  successfully  developed  merely  as  a  procedure  to 
supplement  the  corrective  program. 

The  school  can  greatly  strengthen  its  educational 
practice  by  making  the  adjustments  in  its  equipment 
and  procedure  demanded  by  the  health  program. 
On  analysis  these  will  be  found  consistent  ^^ith 
successful  educational  experience.  Indeed  our 
health  program  well  exemplifies  what  has  been  called 
"the  normal  estate  of  effective  learning,  namely  that 
knowledge-getting  be  an  outgrowth  of  activities  hav- 
ing their  own  end."* 

*  Dewey,  John,  Democracy  and  Education,  The  Macmillan  Co.,  1916, 
p.  229. 


APPENDIX  A 

Distribution  Table  of  Percentages  Over  and 
Underweight 

This  distribution  table  was  compiled  from  the  re- 
sults of  measurements  taken  in  February  1918.  It 
therefore  reflects  the  comparative  status  of  children 
in  the  several  grades  represented  at  a  season  when 
the  period  of  maximal  weight  increase  is  over  and 
before  effects  from  the  period  of  minimal  weight 
increase  have  become  appreciable. 


258 


APPENDIX  A 


259 


Distribution  Table  op  894  Children  According  to  Percentage 
Over-  and  Underweight  * 


Percentage 

Grade 
VII 

Grade 
VI 

Grade 
V 

Grade 

I 

Terman 

Open 
Air 

67 

1 

49-44 

1 

1 

44-39 

39-34 

2 

1 

34-29 

1 

1 

1 

29-24 

4 

24-19 

3 

2 

1 

1 

19-17 

1 

2 

17-15 

4 

2 

1 

1 

15-13 

3 

8 

3 

2 

13-11 

7 

5 

3 

2 

2 

11-9 

3 

8 

4 

6 

2 

9-7 

14 

9 

7 

13 

1 

1 

7-5 

8 

11 

9 

24 

2 

2 

5-3 

17 

19 

11 

24 

12 

3-1 

13 

23 

13 

27 

3 

3 

1-1 

16 

31 

6 

35 

9 

2 

-1-3 

23 

28 

13 

24 

8 

1 

-3-5 

22 

24 

16 

29 

3 

4 

-5-7 

11 

30 

11 

22 

6 

5 

-7-9 

8 

12 

10 

14 

11 

1 

-9-11 

6 

10 

4 

13 

2 

2 

-11-13 

7 

6 

5 

11 

2 

2 

-13-15 

3 

2 

2 

2 

-15-17 

1 

5 

1 

3 

2 

1 

-17-19 

4 

3 

2 

-19-24 

.... 

1 

-24-29 

1 

-29-34 

1 

Total.  .. 

173 

245 

127 

255 

69 

25 

*  Computations  for  this  table  were  made  hj  Dr.  David  Mitchell 
and  the  figures  originally  published  in  his  article,  Malnutrition  and 
Health  Education,  Pedagogical  Seminary,  March,  1919.  They  are 
reproduced  here  by  permission  of  the  Pedagogical  Seminary. 


APPENDIX  B 

Individuul  Record  Sheet 

The  record  form  used  by  us  at  P.  S.  64  is  a  single 
sheet,  8"Xl4i/2",  folded  twice  to  make  a  six  page 
folder  of  5"X8"  filing  size.  It  may  thus  be  used  to 
hold  supplementary  sheets  or  correspondence  rele- 
vant to  the  case  history  but  is  definitely  planned 
to  cover  the  essential  facts  of  the  physical  history 
and  examination,  social  history  and  class  record  on  a 
single  form  and  thereby  avoid  as  far  as  possible  the 
necessity  for  additional  records.  While  further  ex- 
perience has  suggested  a  few  changes  of  detail  in 
this  record,  space  for  some  additional  notations,  as 
for  stool  and  urine  examinations,  and  elimination 
of  some  non-essential  details,  it  has  been  found 
fairly  satisfactory  for  our  purpose  and  of  particu- 
larly convenient  size  for  filing. 

The  fascimile  of  page  1  shows  at  the  right  the  items  for 
identification,  name,  address,  etc.,  printed  on  page  5  but 
appearing  at  the  top  when  the  record  is  folded  and  filed. 
Page  1  contains  the  final  summary  and  weekly  record  for 
19  successive  weeks  and  this  is  extended  to  include  44  weeks, 
the  spacing  for  the  last  25  weeks  covering  page  6  when  the 
record  is  folded. 


260 


APPENDIX  B 


261 


W 


n3 


93 


, -II  iii^i 


I 


ii'MMil 


!  I    I   i-  I  .1   M  I    p4i    M  I 


I   I    I   I 


I  A  I  ill    1  M   I  »   I    (   I 


I  (   1   M  I   (   t 


i 


Si 


I   Mil 


1  I 


0|b 


V\^i>.i.i^:iA-i:i     :i:i:>:i^^-:^^^ 


^■\  111  I  U   ,   1 


I    1  (   Cl   M    I  I    I      1  M  I    I  I  I    f  I 


tr»  fO  "*  r>y  t^ 
♦S    d  <K  flS  e< 


'^   r<  V<        r(  T^  f^  tX 


<  Q  ci  o  2  ci  ~  ~  —       —  o  s       ^ 


«<  «<  'H    r(   rj 


o 

(V 


in     I  1  I  I  1  t  I  I  I    -^ 


(  1  ,  1  1 1  I  I  ,    - 


^   >/•  v>  ^ 
i  cT  a  —  ~ 


^  N.c^t^  f«»t^/-«.c-^  r>»c-^s.  ts.f^  f*»rs,^»^i»»i>-t^ev. 


>8  f>«w^  ^  ^ — ^^p-vS'^sa       v9  t«*  Nfif  v9  r**v3  n3' ^  ^v. 


I     I 


1  V?  I 


»         / 


1  'S   M  I  '    I 


1^1   I  ■'  -i  I 


bLU 


K    I   ^-    I  C^ 


cr-^^^i^O^ 


>.  (T  "i.. 


iSiSiiiS 


262  HEALTH  EDUCATION 


PHYSICAL    EXAaiNATION 


INSTBCnON:    BrllM      i/    dull  frerroui       l/      pld«tra«llo 

DSVKLOFMKNT:   Good  ttlu    •^    poor  UUSCLES:   rre  ••»» 

flKNI&U.  CONDITION:    Ceod  r>lr  4^     poM 

BXAD:   NonoAl       •  •        IkMia  promlnflnt  Pedtcull    t^ 

STBS:   fMpOi  (no   •'     nemct  to  ll>li»-<U>UDea     i/  UoUou:   a«r  l/omm.       Bi«ta.1 

KAlOl:   Oear      ^   matM  Hunxu  dlichui*  Scar  0«llatedl«MB 

MOOTB:   K«aal       wot   V^Cowk        Banto        Miina  MOk.         xmit        WU  •'<• 


TUNUUB:    Kormtl  nwlat    t/^  tfry  tL  whlfffcoat 

fB&OAT:  Koratl  eonjcateil  grtoulir     ^.  RracCM 

T0N8IL8;    Konsal  Iftrro  bulled  eryptio   yC*    laflUMd 

OLANDB:    Norad  cnlmal  Ant-«rTlci]  'f— f      Fort-oan.    -f- 

TKBT^:     Good  No.  dccaysd  Appitoxlmatlon  food    \/^      poor  Stalaod 

■Alts:   BUbtdnin:   Konnil    l^     dull  ntractod  bulilnc  Omvam 

Un    drum:  Nonnd  dull     l/^    retracttd  bultklf  Cama 

nVAItT:   Arat  dttBuM  io'S"    c.  m.  left  m]d-«t«nnl  ttM 

/  •  ^        t  m.  right     "  • 

Ap«  4tb      em  1/  eui     n>K<  is  nippi*  im 

«:  D.  outild*       ••       •• 

a  m.  iDjlda         **       *       , 
Action:  nma  Imsnlu    *^   Boundi;  dMi  ia**m 

Tbrlll:    pnaaot  nooa     b^   A3      'PI 

Bnnmui;    nona 


tr.  la 


•nt  oinair  I 
old.     " 
aagia  of  sois 


•oft  era.  >^  (  cva     v^ 
toud  era.  at    J    pulrponla 
dloatollo         I    aortic 
LDKOB:   Raaonanco  food  throustiont     V^    D'Eapina  10     /       dor.  f«lt«bf« 

ZlceplraUoo  "  ••  \/^ 

ABOOMBN:    Normal    y^  lanra  |u  dlatended  muflllc  aaftr 

Eerala 

LlTer:  dulfaieaa    U?     apace  rib  to  eootal  toider  olxM  ■■• 

EVIeen:  telt  not  felt  l^ 

CBMITALS:   Norma]     ^^        Pr«vuco:  loaf  tdharcDl  drvoaateai    #^^ 

CXTItEMITIES:    K    J.r   praent  and  eoual   ^     aljaeot 

Edema        "  ••       %^ 

eKlN:   Sraooti  0~yw»*i  dear  s^-tra  Vacdnaaoei:  praaaol  j/  atMM 

Facsimile  of  page  2— Individual  liecord  Sheet.— Nota- 
tions on  Physical  Examinations, 


APPENDIX  B  263 


PHVSICAt    EXAMINATION    (Ciatllind) 


BrtNE:    Konntf    I/'  Latanl  currattu*— riibl  l<A 

Bauaa*  BoUQd  tboulden    ^/^  WtaifM  OHplIlM  t/' 

CHEST:    Nonntl  l/       kur*  IM  IBmd  plteoB  B'tffixira 

Test.    ArtJMT  eood  ^/^    pionited  BtiUon:  (ood   *^^  pool 

Otlt:    ly^ 

BSCOJCKEKDATION-B:  I  O-'^^f-'J-O  C*,«Jtjt?. 

Boar  Cteek-    V     lBdJ«t«i  defect  prcHot  Ua*  driwB  Cirousb  vord  tndle«t«*  catmlsad  nd  OOBB 

IndlCTto  degw  by  4,  «1cp. 

SUPPLEMENTARY     INFORMATION 


DICTATSD  TO         0«  '3  .-'S  » 

Facsimile  of  page  3 — Individual  Record  Sheet. — This 
page  continues  the  notations  made  during  the  physical  ex- 
aminations and  affords  space  for  supplementary  notes  on 
physical  couditioa. 


264 


HEALTH  EDUCATION 


SOCIAL    FACTS 


INTORiUTION   RECAIIDINO   MEUBERa   OP  FAUILT 


TdLcXw 


Balatlfloalilp 
ta 

An 

BedUi 

DiTcca 

Dud 

HUkniUtr 

Um<C 

ChUd 

R 

4U 

KvL-f>JKf^^ 

M 

3^ 

«» 

S(m*lIh 

-t 

13 

h-^-^ 

13. 

iJL 

k«cs. 


'Ificlude    gtm-bont    and    miscarrlves    tn    order. 


DTPOBiUTION   BEGilUJtNO    BIBTH   AND    INFANCY 

Bora  tl  fuU  term      \x 

"     "         a<». 
Dreut-fed  ) )  jy^^BoiUe 

Libor     /I                         Oondiaoii  tt  MrUx    |f^> 
Ulzad              IstToothit  lMj^W>lltal»   V3     apotott|X| 

rnsTioua  diseases  (with 

DATES) 

«~i"     l&-lA>-«r». 

Cblclnn-pox     —                      TbuUlUi   — 

Msmix     ^— « 

RhsoniftUsio    ,^^^                    Ooonltkxtt  ^^^ 

8e>rl«t-fe»«  — 

UnlDflUi     —    '■                     Cbm*    — 

DllfaUialt     — 

PiiRiiiiaiili  OptnUou  _ 

Whooirtr-ff-eowtl    — - 

Bnmchltlf    — — ' 

OENEIUI.  HEALTH  AND  HABITa 


Ainwaw  <«peclaUj  for  breikfut)  P^^|>Jj       K»U-MtlBl     "~* 
Il4fulAr1l7   of   meaJ*         f<  ^ci  «  Bed'Wettmt    -«*• 


Bovtli        U> 
Seadsche     

FftqtieQi  eoU<  ^ 
COKDITION  OF  FLAT 
ana        i/*" 
FuraiAhJfio 


'^ 


Va  Is  looa.   ^^ 

-  -  b.d  i^ 

lau)  oa   booi*      /©  -—  8'-  30 


No.   Boom*     3 


Gv.^«vUtXt 


S.S.S^.    /I^O./fcjur-C      1?./^ 


Facsimile  of  page  4 — Individual  Record  Sheet. — Social 
facts  and  health  habits  are  recorded  on  this  page. 


APPENDIX  C  265 


•OPPLEHEMTARY  JHFO    HATIOM 


PtXAAALltc.  UAA.tA<  <4_-  -L*-erU»jUC  -^-'-i^4-  pXAO-*  OAxf."^ 

^O^Xaa,  -tXJL<-Jl==>    CJL^AJ-*-*.    <V^o^0«^   VVaAJCLc  -  J:;^  ^'^'°^'V> 

*r.i8-.l7;^.    U-0^>v.>OU       1)~A(Vl.      FoUJLuM. 


4: 


r 


I 

i 


o 


^ 


^j> 


t 

Facsimile  of  page  5— Individual  Record  Sheet. — Sup- 
plementary information  recorded  on  this  page  covers 
social  facts  and  miscellaneous  details. 


APPENDIX  C 

Specimen  weight  charts  with  adaptations  made 
during  the  course  of  the  experiment. 

The  weight  charts  used  at  P.  S.  64  were  of  heavy 
white  paper  24"X19".  Charts  Xa  and  Xb  *  show  the 
original  form  used  during  the  first  school  term. 
The  name  of  the  child  is  placed  in  large  letters 
across  the  top  and  dates  of  the  weekly  class  meet- 
ings are  recorded  jast  below  in  the  first  two  rows. 
Stars  appearing  in  the  third  and  fourth  rows  fol- 
lowing the  words  ''Lunches"  and  "Best"  indi- 
cate that  the  child  has  followed  his  prescribed 
regime  in  regard  to  lunches  and  rest  on  each 
day  of  the  week  so  marked.  Figures  in  the  left- 
hand  column  indicate  pounds  and  are  determined 
by  placing  at  the  bottom  of  the  column  a  number 
two  or  three  pounds  below  the  actual  weight  of  the 
child  at  the  time  of  enrollnaent.  Figures  in  the  last 
row  following  the  word  ' '  calories ' '  indicate  the  num- 
ber of  hundred  calories  averaged  per  day  as  esti- 
mated from  the  48  hour  record  taken  weekly.  The 
heavy  irregular  line  running  across  the  chart  is  the 
record  of  the  weekly  weight  taking  showing  the  suc- 
cessive increments  and  losses  of  the  individual  for 
whom  the  chart  is  kept.  Dotted  lines  indicate  holiday 
periods  and  absences.  The  heavy  straight  line  above 
is  the  "Line  of  Normal  Expected  Gain"  and  repre- 

•  Eeproduced  by  permission  of  the  Pedagogical  Seminary. 

266 


APPENDIX  C  267 

sents  the  week  to  week  weight  increment  for  a  child 
of  normal  weight  and  of  the  same  height  and  age. 
(For»compiitation  of  this  line  see  footnote  p.  51). 

Xa  shows  a  satisfactory  record.  The  child  in 
question  was  8  pounds,  9%,  underweight  when  en- 
rolled and  in  13  weeks  gained  9I/2  pounds,  bring- 
ing him  within  2%  of  normal.  It  will  be  readily 
appreciated  that  where  the  individual  makes  this 
kind  of  response,  the  line  of  normal  expected  gain 
acts  as  an  incentive  to  effort,  and  it  will  be  equally 
clear  that  for  the  child  Xb  the  effect  of  the  line  of 
normal  expected  gain  is  discouraging  to  effort. 
This  child  was  I31/2  pounds,  17%,  underweight  when 
enrolled  and  at  the  end  of  19  weeks  had  gained  but 
3  pounds  and  was  still  13i/^  pounds,  16%,  under- 
weight. 

Charts  Ya  and  Yb  *  show  the  form  used  for  the 
fifth  grade  and  open-air  classes  during  the  second 
winter  and  have  the  line  of  normal  expected  gain 
paralleled  by  a  line  of  '' Individual  Expected  Gain'* 
that  starts  from  the  point  indicated  by  the  child's 
actual  weight  at  enrollment  and  progresses  by  the 
same  weekly  increments.  The  two  lines  thus  form 
a  zone  within  which  progress  may  be  considered 
achievement.  Ya  is  a  low  percentile  case  showing 
satisfactory  progress:  He  was  5  pounds,  8%,  un- 
derweight when  enrolled,  gained  8  pounds  in  30 
weeks  and  was  then  within  1%  of  normal.  Yb  on 
the  other  hand,  is  a  high  percentile  case,  whose  re- 
sponse is  unsatisfactory.  He  was  12  pounds,  17%, 
underweight  when  enrolled  and  after  30  weeks  was 
14  pounds  or  18%  underweight.    It  will  be  appar- 

•  Reproduced  by  permission  of  the  Pedagogical  Seminary. 


268 


HEALTH  EDUCATION 


Date  lib  .March        April  May       dunQ 

22   I     &    IS  22  Z9  3     \Z   i9  26  J    /o    J7  2413/  "^     14  2) 
^  ^   ^   ^  ^  J^:** 


2J  J-f         20  2^9a9SS        26Z9Zt 


CHART  Xa. 

Showing  Line  op  Nokmal  Expected  Gain — a  Satisfactory 
Record. 


APPENDIX  C 


269 


Datcfcbruory    March      April         May     dune 

S   IZ  19  ze  5  IZ  19  Z6  2.    9  W^  2J  JO  7    1^  Zf  ZS  -^  /I   /& 


Ll/nch»t 
Rest 
85 
84 
83 
82 
61 
80 
79 
78 
77 
76 
75 
74 
73 
72 
II 
70 
69 
63 
61 
60 
65 


*  *  *  * 


*  *  3^ 

*  *  * 


^^     ^"       ^       ^v      ^^     '^»      ^ 


liohJi 


n     .Z2. 


Z6  Z3 


23 


CHART  Xb. 

Showing   Line   op  Normal  Expected   Gain — an  Unsatisfactory 

Record. 


270 


HEALTH  EDUCATION 


M^X 


w^65  lb 

a::: 


P«  Cau.  Uulaw^ki 


fTT1^ttt?tt  ^ntttl  j^HT^t^  ilitl!^ 

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70 


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iMiMMMiMiiM    l<r 


CHART  Ya. 

Showing  Zone  Formed  by  Line  op  Normal  Expected  Gain  and 
Line  op  Individual  Expected  Gain — a  Satispactory  Record. 


APPENDIX  C 


271 


lb 


■^0  Cent  Uukrwo^. .  .  M,  fl -  ■ 


14  0    9  1 4    ^   40  15  12  18  ^    IS  U  |*    »»  ^    «0a»         1** 


73 
72 
71 

70 
69 

es 

67 
66 

65 
64 

63 
63 
61 
60 
59 


21^1 


CHART  Yb. 


Showing  Zone  Formed   by  Line   of  Normal  Expected  Gain  and 
Line  of  Individual  Expected  Gain — an  Unsatisfactory  Record. 


272  HEALTH  EDUCATION 

ent  that  for  this  boy  the  struggle  to  approximate 
his  individual  line  of  expected  gain  was  unsuccessful 
during  the  season  of  minimal  increase,  and  the  pres- 
ence of  the  line  of  normal  expected  gain  could  have 
had  no  significance  for  him  except  as  a  discourage- 
ment. 

Some  changes  in  addition  to  the  line  of  individual 
expected  gain  will  be  noted  on  these  charts  (Ya  and 
Yb).  Actual  dates  of  the  class  meetings  have  been 
replaced  by  their  numbers,  1,  2,  3,  4,  etc.,  indicated 
by  the  figures  in  the  fourth  row  from  the  top.  Best 
periods  and  lunches  are  recorded  in  the  first  and 
second  rows  and  the  stars  used  are  supplemented 
by  figures  indicating  the  number  of  days  during 
the  week  that  the  regime  was  followed,  the  star 
signifying  that  the  regime  was  observed  every 
day  of  the  school  week.  The  records  of  caloric  in- 
take follow  in  the  third  row.  The  three  last  rows 
are  used  to  indicate  the  presence  of  defects  needing 
correction  and  the  taking  of  tea  and  coffee.  A  black 
sticker  placed  in  the  row  opposite  the  words'* Ton- 
sils, Adenoids"  shows  operation  has  been  recom- 
mended and  is  repeated  every  week  until  removal, 
when  a  gold  star  is  used.  (See  chart  Ya  where  op- 
eration was  performed  in  the  eighteenth  week  and 
is  followed  by  a  loss  of  3  pounds  in  weight  and 
rapid  gain  after  3  weeks  absence.)  A  gold  star  was 
also  used  to  record  the  greatest  gain  in  pounds  made 
in  each  class  during  each  week.  For  this  Ya  re- 
ceives three  gold  stars  at  different  points  in  his 
progress,  and  Yb  in  spite  of  his  poor  record  later, 
receives  one  the  third  week  after  his  enrollment. 


APPENDIX  C  273 

Dental  defects  are  indicated  in  the  row  below  by 
figures  showing  the  number  of  defective  teeth  found. 
As  these  are  treated  the  figures  are  reduced.  Fig- 
ures in  the  last  row,  following  the  words,  *'Tea, 
Coffee,"  indicate  the  number  of  times  these  stimu- 
lants were  taken  during  the  week. 

Chart  Z  shows  the  form  used  for  the  first  grade 
children  during  the  last  winter  of  the  experiment. 
Only  the  line  of  individual  expected  gain  is  used  for 
comparison  with  the  week  to  week  increments  and 
all  gains  in  excess  of  that  appear  as  achievement. 
Thus  the  efforts  of  the  children  are  directed  to 
*' beating  their  own  record''  and  the  greater  appar- 
ent success  attending  their  attempts  serves  to  stim- 
ulate further  endeavor.  Z  is  a  high  percentile  case, 
being  7  pounds  or  16%  underweight  when  enrolled. 
After  an  initial  gain  of  3  pounds  in  the  first  three 
weeks  he  averages  from  31/2  to  1^/4  pounds  in  excess 
of  his  expected  gain  at  each  weight  taking  for  32 
weeks  when  he  is  3^2  pounds,  7.5%,  underweight 
for  height.  One  other  feature  added  to  the  chart 
in  this  last  year  was  the  red  crayon  dot  by  which 
the  child  himself  recorded  the  result  of  the  weight 
taking  under  the  nutrition  worker's  supervision. 
He  placed  the  dot  in  the  proper  square  and  the 
weight  line  was  filled  in  by  the  nutrition  worker 
afterwards. 

In  the  light  of  subsequent  experience,  some  fur- 
ther modification  of  the  weight  chart,  or  at  least  of 
the  line  of  expected  gain  to  reflect  seasonal  varia- 
tion suggests  itself.  It  will  be  evident  that  these 
lines    as    computed    on    aU    charts,    whether    for 


274 


HEALTH  EDUCATION 


-16 


47 
46 
45 
44 
43 
42 
41 
40 
39 
38 
37 
36 
35 
34 


Showing  Adaptation  Finally  Made  Using  Onlt  Line  op  Indi- 
vidual Expected  Gain. 


APPENDIX  C  275 

Normal  Expected  Gain  or  for  the  Individual  Ex- 
pected Gain  represent  a  rate  of  increase  too  low 
for  the  season  of  maximal  increment  and  too  high 
for  the  season  of  minimal  increment. 


APPENDIX  D 

Relative  eficiency  of  differing  provisions  afford- 
ing advantageous  factors  in  the  school  environment. 

Before  our  provisions  for  health  education  can  be 
placed  on  the  most  efficient  basis,  a  considerable 
program  of  experiment  remains  to  be  undertaken. 
The  relative  value  of  various  provisions  for  supply- 
ing advantageous  factors  in  the  school  environment 
has  yet  to  be  determined,  and  experiment  is  espe- 
cially needed  in  respect  to  provisions  for  school  feed- 
ing and  ventilation.  This  can  only  be  accomplished  by 
consistently  following  such  a  program  as  was  at- 
tempted in  the  first  year  of  our  work,  that  of  estab- 
lishing parallel  groups  of  children  on  a  basis  as 
nearly  equal  as  possible,  but  with  different  variables 
as  points  of  comparison. 

Comparable  groups  of  children  should  he  studied 
under  varying  conditions  of  ventilation  with  a  view 
to  determining  more  definitely  the  influence  on 
growth  of  optimum  conditions  in  respect  to  temper^ 
ature,  humidity,  and  movement  of  air.  The  facts 
of  seasonal  variation  establishing  the  fall  months  as 
the  period  of  maximal  weight  increase,  suggest  the 
favorable  influence  for  nutritional  processes  of  var- 
iable, but  not  extreme  temperatures  and  open  win- 
dows, in  comparison  vnih  extreme  outdoor  cold  and 
the  heated  indoor  atmospheres,  with  low  humidity, 

276 


APPENDIX  D  277 

and  lack  of  air  currents,  that  characterize  our  win- 
ter conditions  in  the  latitudes  of  New  York  and 
Boston.  Comparison  of  the  results  secured  in  the 
open-air  and  fifth  grade  classes  during  the  second 
winter  of  our  experiment  appears  to  confirm  the 
hypothesis  that  conditions  of  ventilation  materially 
influence  the  nutritional  processes,  and  that  week  to 
week  observations  of  growth  in  children,  under  con- 
ditions calculated  to  isolate  the  factors  of  tempera- 
ture, air  movement  and  humidity,  would  result  in 
some  definite  accessions  of  knowledge  in  respect  to 
the  importance  of  these  as  advantageous  factors  in 
the  school  environment.  The  numerous  experiments 
previously  undertaken  in  this  field  have  yielded  only 
negative  data  in  respect  to  the  etfect  of  ventila- 
tion on  health,  as  in  the  case  of  the  investigations 
conducted  by  the  New  York  Ventilation  Commission, 
or  have  attempted  to  draw  conclusions  from  groups 
not  strictly  comparable,  under  conditions  not  strictly 
parallel  in  respect  to  other  advantageous  factors. 
This  is  true  of  the  numerous  comparisons  attempted 
between  open-air  and  indoor  classes.  Children  of 
anaemic  or  pre-t'ubercular  condition  usually  form 
the  major  part  of  the  open-air  groups,  and  are  given 
the  special  provisions  characteristic  of  the  open-air 
class  in  addition  to  the  modified  atmospheric  condi- 
tions. For  years  a  battle  royal  has  been  waged  in 
the  schools  by  and  against  the  advocates  of  open- 
air  classes.  But  for  the  most  part  investigators  have 
been  concerned  with  comparisons  of  the  learning 
process,  and  after  reporting  on  the  negative  results 
obtained  from  these,  have  been  content  to  confess 
that  they  have  had  no  standards  by  which  to  evalu- 


278  HEALTH  EDUCATION 

ate  physiological  effects.*  Physiological  effects, 
however,  are  precisely  what  the  health  program 
must  consider.  Especially  is  this  true  of  a  program 
that  seeks  to  increase  physical  vigor  through  im- 
proved nutritional  status.  We  must  agree  with  Dr. 
Burnhamf  that  experiments  to  date  have  not  been 
carried  far  enough.  They  are  inconclusive  so  far 
as  our  problem  is  concerned.  For  this  reason  we 
suggest  an  extended  study  of  week  to  week  growth 
increments  under  at  least  four  contrasted  methods 
of  ventilation  found  in  our  schools  at  the  present 
time.  This  study  should  be  undertaken  with  groups 
of  children  strictly  comparable  as  to  average  physi- 
cal status,  age  period,  mental  ability  and  conditions 
of  class  environment. 

Since  experience  has  shown  that  open- window  and 
open-air  classes  must  be  provided  with  mid-session 
lunches,  rest  facilities,  and  frequent  brief  periods  of 
bodily  activity  in  cold  weather,  we  cannot  isolate 
the  influence  of  atmospheric  conditions  in  an  inves- 
tigation of  groups  where  an  open-air  class  is  in- 
cluded, unless  we  supply  these  special  conditions  to 
all  the  groups  studied.  Thus  our  investigation  In- 
stead of  contrasting  standard  school  conditions  with 
the  special  environmental  conditions  found  in  the 

•  McCall,  Wm.  A.,  Proe.  Conference  Women  Physicians.  Vol.  III. 
pp.  46-63,  Womans  Press,  1920. 

t  Burnham,  Wm.  H.,  The  Optimum  Humidity  for  Mental  Work, 
Pedagogical  Seminary,  Dec, -lOig,  pp.  311-329.  "The  esperimenta 
by  the  New  York  Commission  strongly  suggest  that  excess  of  tem- 
perature or  the  bad  odors  of  stale  air,  or  both  these  together  modify 
the  general  metabolism  since,  as  we  have  seen  these  investigators 
found  that  by  working  in  bad  air  and  overheated  conditions  the 
appetite  of  their  subjects  was  diminished.  Thus  while  for  the  time 
being  no  appreciable  effect  on  the  working  ability  was  noticed,  prob- 
ably continued  work  in  these  conditions  would  be  injurious  to  the 
health  and  decrease  efficiency. '^ 


APPENDIX  D  279 

open-air  class  would  add  the  advantageous  factors 
of  the  open-air  class  (with  the  exception  of  atmos- 
pheric conditions)  to  the  usual  environment.  In 
this  way  we  might  hope  to  isolate  the  effects  on 
growth  of  the  varying  conditions  of  atmosphere  af- 
forded by  the  following  provisions : 

Open-air  or  open-window  class  with  artificial  heat  to  ensure  a 
temperature  of  55  degrees.  (The  generally  accepted  provision  in 
latitudes  like  New  York  where  extreme  winter  cold  prevails.) 

Closed-window  class  with  artificial  heat  and  direct  ventilation. 

Closed-window  class  with  artificial  heat  and  forced  air  ventilation. 

Closed-window  class  with  artificial  heat  and  forced,  humidified  air. 

A  parallel  series  of  observations  on  groups  of  nor- 
mal children,  low  percentile  underweights,  and  high 
percentile  underweights,  under  these  varying  condi- 
tions of  environment,  should  prove  of  proportion- 
ately greater  interest  and  importance. 

Comparable  data  on  parallel  experiments  in  school 
feeding  should  determine  the  character  and  place  of 
the  school  lunch  in  a  corrective  program.  The 
school  lunch  for  malnourished  children  had  origi- 
nally but  a  single  purpose,  to  fill  the  hungry,  and  pop- 
ular thinking  on  the  subject  to-day  is  largely  colored 
by  the  eleemosynary  character  of  its  beginning. 
Soups  and  stews  have  been  provided  in  our  public 
school  lunch  rooms  for  many  years  with  a  view  to 
satisfying  hunger,  and  such  returns  in  weight  in- 
crease as  have  resulted  have  been  accepted  without 
question,  because  in  the  minds  of  those  responsible 
for  the  menus,  relief  measures  rather  than  stimula- 
tion of  growth  have  been  the  major  consideration. 
Increasing  realization  that  the  function  of  the 
school  lunch  in  a  corrective  program  is  educational 
and  remedial  has  not  served  to  alter  the  character 


280  HEALTH  EDUCATION 

of  the  menus  generally  offered  to  the  extent  that  the 
newer  conceptions  of  feeding  demand.  Questions  of 
relative  convenience,  expense  and  tradition  largely 
govern  the  selection  of  the  foods  supplied,  and  so 
simple  a  piece  of  research  as  the  gathering  of  data 
on  the  comparative  weight-getting  value  of  the  dif- 
ferent types  of  mid-morning  lunches,  whether  of 
milk,  of  cocoa,  of  soup  or  of  cereal  and  milk,  remains 
to  be  attempted.  We  have  no  statistics  by  which  to 
gauge  the  advantages  of  the  mid-day  dinner  planned 
as  a  model  balanced  meal  in  comparison  with  those 
of  a  meal  planned  to  supplement  particular  deficien- 
cies in  the  home  dietaries.  Yet  every  worker 
responsible  for  dinner  menus  in  a  corrective  pro- 
gram is  called  on  to  decide  between  these  two 
methods  of  attack.  The  dinners  provided  by  the 
New  York  School  Lunch  Committee  during  the  first 
term  of  our  work  were  planned  on  the  second  basis, 
with  a  view  to  supplementing  home  dietaries  that 
were  conspicuously  lacking  in  milk  and  vegetables 
and  for  the  most  part  low  in  caloric  value.  The 
greater  knowledge  of  food  accessory  substances  that 
is  rapidly  becoming  a  part  of  general  thinking 
to-day,  suggests  the  desirability  of  still  further 
departure  from  the  model  balanced  meal  when  stimu- 
lation of  growth  is  the  specific  aim  in  view.  And 
thus  the  question  arises  whether  the  emphasis  placed 
on  milk  and  vegetables  in  our  best  current  programs 
might  not  profitably  be  extended  to  include  the 
liberal  use  of  fruit  juices  and  tomato  juice,  possibly 
of  yeast,  to  stimulate  appetite  and  increase  vitality. 
Experience  has  pretty  clearly  shown  that  what- 
ever lasting  results  in  growth  are  to  be  secured  from 


I 


APPENDIX  D  281 

the  feeding  program,  must  in  the  final  analysis  de- 
pend on  the  modification  of  the  home  dietary  as  a 
result  of  tastes  cultivated  or  convictions  established 
through  the  school  experience.  Hence  the  relative 
efficiency  of  the  school  menu  cannot  be  determined 
in  advance  merely  by  considering  its  constituent  food 
values.  Careful  evaluation  of  the  actual  returns 
from  various  programs  is  the  necessary  basis  for 
real  progress  in  this  field. 


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